bca's Series of Pocl<et Text=5ool<s. 



PRACTICE OF MEDICINE. 



A MANUAL FOR STUDENTS AND PRACTITIONERS. 



BY 

GEORGE E.'mALSBARY, M.D., 

Assistant to the Chair of Practice, Medical College of Ohio, University of Cincinnati; Assist- 
ant to the Lectureship of Clinical Medicine, Good Samaritan Hospital, Cincinnati. 



SEEIES EDITED BY 

BEEN B. GALLAUDET, M.D., 

Demonstrator of Anatomy and Instructor in Surgery, College of Physicians and Surgeons, 
Columbia University, New York ; Visiting Surgeon, Bellevue Hospital, New York. 



ILLUSTRATED WITH FORTY-FIVE ENGRAVINGS. 




LEA BROTHERS & CO., 
PHILADELPHIA AND NEW YORK. 



Entered according to Act of Congress, in the year 1899, by 
LEA BROTHERS & CO., 
In the Office of the Librarian of Congress, at Washington. All rights reserved. 




•ECOND OOPY, 



WESTCOTT & THOMSON, 
ELECTROTYPERS. PHILADA. 



PREFACE. 



Medical progress is so rapid in oar clay that Manuals 
have special value, in that they may be published in the 
shortest possible time, and thus place before the reader the 
most recent advances in Medicine. Moreover, a brief epit- 
ome presents the subject to the busy practitioner and student 
in a form more readily accessible than is possible in a lengthy 
treatise. 

All the standard authors of the day have been consulted 
in the preparation of this book, and the author trusts that it 
will prove a valued assistant to the student. 

GEOEGE E. MALSBAKY. 

Cincinnati, Ohio, 

3 



CONTENTS. 



CHAPTER I. 

PAGE 

Infections 17 

CHAPTER II. 
Diseases of the Organs of Digestion 168 

CHAPTER III. 
Diseases of the Organs of Respiration 250 

CHAPTER IV. 
Diseases of the Organs of Circulation 293 

CHAPTER V. 

Diseases of the Blood 335 

CHAPTER VI. 
Diseases of the Genito-Urinary Organs 364 



6 



PRACTICE OF MEDICIXE. 



CHAPTER I. 

INFECTIONS. 

DISEASES CAUSED BY VEGETABLE PARASITES. 

SEPTICEMIA (Pyaemia; Septico-pysemia ; Sepsis). 

Definition : Septiccemia is a septic infection, due to the 
presence of the prod acts, toxins, of pyogenic (pus-produc- 
ing) micro-organisms in the blood and tissues of the body. 
Pycemia is an infection of the blood and tissues of the body 
by pyogenic micro-organisms. In septicaemia the symptoms 
of blood-poisoning predominate ; in pyaemia, the symptoms 
of metastatic abscesses. A combination of septicaemia and 
pyaemia constitutes sept'ico-pycemia. Usually all these cfjiuU- 
tions are included under the term septiccemia when there is 
general infection of the blood. Localized infections or in- 
flammations have received special names — e. g., meningitis, 
pleuritis, peritonitis, arthritis, metastatic abscess, etc. The 
condition caused by the absorption of toxins only, from a local- 
ized septic infection, is known as septic toxcemia. 

Etiology : The micro-organisms most frequently encountered 
in septiccemia are the staphylococcus pyogenes aureus, which 
produces chiefly circumscribed abscesses, and the streptococ- 
cus pyogenes, which produces extensive suppuration. Puer- 
peral septicaemia (puerpercd fever) is usually caused by the 
streptococcus pyogenes. Other micro-organisms which act as 
etiological factors are the staphylococcus pyogenes albus, the 
staphylococcus pyogenes citreus, and the micrococcus pyo- 

2— P.M. 17 



18 



INFECTIONS. 



genes tenuis. More rare are the pneumococcus, the bacilhis 
coli communis, and the bacillus of malignant oedema. 

The micro-organisms gain entrance to the circulation 
through some break in the surface of the body, which may 
be caused by traumatism (wounds, parturition), or through a 
lesion produced by some other infection (tuberculosis, small- 
pox, dysentery, gonorrhoea), thus constituting a i^econdary in- 
fection. Cases of cryptogenetic sepsis are those in which the 
local depot of infection may not be discovered. Cases of dis- 
coverable lesion are phaneroge^ietic. 

Infection may be conveyed by insects — e. 9., bedbugs, roaches, 
and flies (Coplin). 

In order that septicsemia may be produced the resistance 
(immunity) of the body to the invasion of micro-organisms 
must be overcome, as in other infections. Special obstacles to 
infection are found in the skin, mucous membranes, the serosse, 
in the small-cell infiltration, lymph-structures, lymph-vessels 
and -glands, the thymus gland, and bone-marrow ; in the ex- 
cretory organs, kidneys, liver, and intestine ; and in the blood, 
where resistance is offered by both the corpuscles and the 
serum. No protective principle has been isolated from the 
blood. It has been proved experimentally that the immunity 
to infection depends largely upon the degree of alkalinity of 
the blood. Immunity is lessened by fatigue, starvation, ex- 
posure to cold, more especially to impure air, bad hygiene, 
and by toxaemia (Bright's disease) and anaemia. 

Septicaemia — symptomatology There may be a })receding 
infection or traumatism. Infection by the pyogenic micro- 
organisms is announced hy chilis and fever, 103°-104°F. ; 
and these are repeated with each new invasion. The eleva- 
tion of temperature is accompanied l)y nervous symptoms, de- 
pression, headache, dizziness, and sometimes vomiting. There 
is profuse sioecdivg. The fever recurs daily or every other 
day, in chronic cases often at longer intervals, with varying 
intensity, and is characterized by its irregularity, constituting 
the " streptococcns-curve^' (Fig. 1), and by its resistance to 
treatment with quinine or the salicylates. The temperature 
may be above or below normal during the intervals. Exami- 
ncdion of the blood sometimes reveals the micro-organism caus- 



SEPTICEMIA. 



19 



ing the disease, and usually shows an increase of white blood- 
corpuscles (leucocytes), a decrease of red blood-corpuscles 
(erythrocytes), and an increase of blood-plaques. Soon there is 
pain in the joints, which are swollen and tender. The spleen 
is enlarged. The skin, at first pale, becomes icteric. The 

Fig. 1. 




streptococcus-curve from a case of phthisis. 



pulse is rapid, often 120-140 per minute, weak and irregular. 
The typhoid state ensues. Evidences of metastatic affection 
may be found, especially in the organs having end-arteries — 
the skin, eyes, heart, kidneys, and brain. 

Septicaemia — diagnosis : This rests upon the infection, chills 
and fever, the sweating, the frequency of the pulse out of 
proportion to the temperature, and the metastases. 

The differential diagnosis concerns chiefly : 

1. Typhoid fever. Both diseases may shoAV an eruption of 
rose-colored spots, fever, diarrhoea, enlargement of the spleen, 
and bronchitis. Typhoid fever has a characteristic tempera- 
ture-curve, very different from the see-saw, irregular " strep- 
tococcus-curve.^' The typhoid state is present much earlier in 
typhoid fever than in septicaemia. The presence of the 



20 



INFECTIONS. 



diazo-reaction (Ehrlicb) in the urine, and the positive re- 
action of the blood to the blood-test for typhoid fever 
( Widal), would make the diagnosis of typhoid fever almost, 
if not quite, absolute. An examination of the blood may 
reveal the micro-organism causing septicaemia ; but such 
micro-organism may be present as a secondary infection in 
cases of typhoid fever. The diseases may co-exist. Ketinal 
hemorrhages, arthritic affections, and mitral lesions would 
speak for septicsemia. 

2. Malaria; in which there is a distinct periodicity of 
fever, usually not to be found in septicaemia. A therapeutic 
test may be made with quinine, which has absolute control over 
malaria but no permanent influence over septicaemia. The 
presence of plasmodium malar ice in the blood speaks positively 
in favor of malaria. 

3. 3filiary tuberculosis, which may sometimes be differenti- 
ated by finding the tubercle bacillus in the secretions and 
excretious. Often there is tuberculosis of the lungs, lymph- 
glands, spine (caries), or hip-joint (hip-joint disease). Obscure 
cases may be cleared up by a test-injection of tuberculin. Sep- 
ticaemia often exists in cases of tuberculosis as a mixed in- 
fection. 

4. Cerebrospinal meningitis: Opisthotonos, hyperaesthesia, 
constipation, and the occurrence of the disease in the colder 
months, in soldiers and children, would speak for cerebro- 
spinal meningitis rather than septicaemia. 

5. Endocarditis, which presents evidence of heart-disease in 
enlargement and bruit. Ulcerative endocarditis is an expres- 
sion of septicaemia. 

6. Urcemia, which shows more severe headache, with twitch- 
ings, convulsions, and coma. In uraemia, there are oedema, 
albuminuria, and tube-casts; there is often also hardness of 
the arteries. 

7. Affections of the joints, rheumatic, post-scarlatinal, or 
gonorrhoea!. These furnish the evidence or history of rheu- 
matism, scarlatina, or gonorrhoea, in the absence of the " strep- 
tococcus-curve or metastatic abscesses. Affection of the 
joints may be an expression of septicaemia as a secondary 
infection. 



SEPTICEMIA. 



21 



Septicasmia — prognosis : The prognosis is grave in all cases; 
but even bad cases may recover. In general the prognosis 
depends upon the possibility of removing or destroying cen- 
tres or depots of infection. Mixed infection ; or infection 
with streptococci, usually gives a more grave outlook than 
infection with staphylococci or pneumococci. The gravity of 
the case may be measured approximately by the height of the 
fever, the weakness of the heart, and the nervous symptoms. 

Prophylaxis : The prevention of septicaemia calls for asep- 
sis (surgical cleanliness) and antisepsis in the treatment of 
wounds. Pus, whenever and wherever recognized, should be 
evacuated. 

Septicaemia — treatment : Bichloride of mercurv solution 
(1 : 1000 or 1 : 2000) or carbolic acid solution (1 : 40 or 1 : 60) 
may be used in the treatment of wounds. The actual cau- 
tery, thermo-cautery, or galvano-cautery is sometimes useful. 
Cryptogenic cases are sometimes cleared up by the deep ure- 
thral injection of a strong solution of protargol or nitrate 
of silver, gr. xx to §j ; or by a curettement of the uterus or 
the removal of a diseased ovary ; or by the relief of a mastoid 
disease by operation. The entrance of infection through the 
respiratory tract may be combated by the use of antiseptics — 
boric acid, lactic acid, subsulphate of iron, etc. Intestinal 
antisepsis may be secured by the use of calomel, salol, 
/9-naphthol, or ichthalbin. 

The frequent failure of serum-therapy in the treatment of 
septicaemia is probably due to the fact that streptococcic 
serum protects only against infection by the particular variety 
of streptococcus from the culture of which the serum has 
been immunized. This is only what should be expected, as a 
large number of organisms which differ widely in virulence 
and other characteristics are included under the term strepto- 
cocci. Protection has been secured against two or three varie- 
ties by immunizing against the two or three germs. The 
streptococcic serums rapidly deteriorate in the vials and soon 
become worthless. Marmorek reports results obtained from 
the use of antistreptococcic serum that are in a general way 
encouraging. 

Sometimes excellent results, and almost always temporary 



22 



INFECTIONS. 



improvement, may be obtained by venesection and infusion of 
normal saline solution. 

Alcohol, best in tlie form of whiskey or brandy, may be 
given in large quantities. In septicaemia alcohol does not 
readily produce toxic effects. It is supposed to increase the 
number of leucocytes and to neutralize toxins. Quinine, gr. 
V, may be given every two to four hours. Toxins in the 
blood may be neutralized by the use of the salicylates, iodine, 
mercury, bromine, or arsenic. 

Fever and pain may be relieved by phenacetin, or in the . 
presence of great weakness by laclophenin. Fever that be- 
comes dangerously high may be controlled by hydrotherapy, 
sponging with cold water. Affections of the heart, joints, 
meninges, pleura, or peritoneum call for application of the 
ice-bag. Obstinate pain and sleeplessness demand the use of 
opium. 

ERYSIPELAS (Saint Anthony's Fire ; Rose, Wundrose, Rothlauf 
(German); Erysipele (French)). 

Definition : An acute infection caused by the streptococcus 
erysipelatis, characterized by inflammation of the skin and 
lymphatics, fever, gastric disturbance, and symptoms on the 
part of the nervous system. 

History : Erysipelas was recognized by Hippocrates and the 
early medical writers, but they did not know the cause of the 
disease. Henle (1840) attributed the disease to minute vege- 
table organisms. Trousseau (1848) pointed out that there 
must be a lesion as a starting-point of the infection. The 
organism now held to be the cause of the disease was discov- 
ered in the skin by Koch and Fehleisen (1881) independently 
of each other. The streptococcus erysipelatis was isolated and 
cultivated by Fehleisen, who also made therapeutic inocula- 
tions in man, and thus definitely established this organism as 
the cause of erysipelas. 

Etiology : The essential factor in the causation of erysipelas 
is an inoculation with the streptococciis erysipelatis, which can 
occur only through a lesion. The abrasion through which 
the streptococcus gains entrance to the body may be so mi- 



ERYSIPELAS. 



23 



nute as to have entirely disappeared by the end of the period 
of incubation. Such eases were formerly termed idiopathic. 
The streptococcus erysipelatis bears a close resemblance to the 
streptococcus pyogenes; and some believe them to be identical, 
or that the streptococcus erysipelatis is a variety of the strep- 
tococcus pyogenes. Erysipelas has been produced 'in man, as 
a therapeutic measure, in the treatment of sarcoma and car- 
cinoma, by inoculation with streptococci obtained from peri- 
toneal pus (Petruschky). The streptococcus erysipelatis may 
be carried by third persons or things (fomites). Cro wading 
favors contagion, and succeeding attacks render the individual 
more susceptible to infection. 

Erysipelas — symptomatology : The period of incubation is 
from two hours (Heiberg) to two weeks (Echlier) ; usually 
one or two days. This period may show^ no symptoms. 
There may be more or less malaise, anorexia, and lassitude, 
such as are common in the infectious diseases. 

The first striking symptom, as a rule, is a severe chill lasting 
from a few minutes to one or tw^o hours, usually about half 
an iiour. With the chill there may be nausea, sometimes 
vomiting. There is fever, 102°-105^ F.; the pulse is fre- 
quent. These symptoms continue a day or longer, w^ith an- 
orexia, uneasiness in the epigastrium, malaise, headache, ver- 
tigo, and possibly delirium. The urine is scanty ; tlie skin 
dry and hot. Before the eruption appears there is often a 
feeling of tension and fulness, sometimes pricking or itching, 
in the affected part. 

The eruption appears upon the face, as a rule, presumably 
because the skin of the face is tender and more exposed to 
infection. The eruption is rose-colored, frequently resem- 
bling an ordinary erythema. The skin is swollen and oedem- 
atous. The eruption, starting usually from the nose, ear, 
eyelids, or scalp, may extend to other parts, but avoids the 
chin; likew^ise, starting from the breast, the eruption tvill not 
appear over the ensiform cartilage. Variations in the course 
of the eruption have given rise to the terms : erysipelas 
migrant, ambulans, serpens, or wandering erysipelas, ^vhen 
the disease affects large areas and continues to advance at one 
part while it disappears at another; erratic or multiple ery- 



24 



INFECTIONS. 



sipelas, in which there are a number of lesions, caused by in- 
fection (inoculation) in several places at about the same time ; 
erysipelas fixum, fixed erysipelas, a localized mild erysipelas, 
a term applied by some to an inflammation around chronic 
ulcers, which, however, is usually not a true erysipelas. 

CEdema causes often marked deformity of the eyes, nose, 
ears, and scalp. The infiltration of the scalp may cause the 
hair to fall out ; to be restored, as a rule, upon the disappear- 
ance of the disease. 

The eruption may involve the mucous memhixme of the ear, 
nose, fauces, pharynx, and larynx, less frequently of the 
vagina and uterus, either by extension from the skin or 
primarily. 

During the height of the disease there are insomnia, more 
frequently somnolence, and coma, with more or less delirium. 
There is constipation, the tongue is coated, and the spleen 
enlarged. When the fever is high there may be albu- 
minuria. 

The general symptoms are probably due to toxoemia. The 
streptococcus erysipelatis has not been found in the blood, 
although it has been found in the urine (Cern6). Others 
claim to have found the coccus in the blood, in which case 
the general symptoms would be due to a ^' specific septi- 
caemia. 

Complications : Mixed infection is not uncommon in erysip- 
elas. Septiccemia {idceratwe endocarditis) is a frequent com- 
plication. Occasionally there is a complicating dermatitis, 
seborrhoea, an affection of the scalp ; abscess of the skin and 
superficial lymphatic glands; gangrene; albuminuria, SLlmost 
constant after fifty ; nephritis, which rarely becomes chronic ; 
pneumonia, bronchitis, pericarditis, meningitis, icterus, dysen- 
tery, enterorrhagia, ulcer of the duodenum, peritonitis, affec- 
tions of the joints, parotitis, conjunctivitis, keratitis, amauro- 
sis, panophthalmia, and paralysis. 

Erysipelas — diagnosis : The peculiar inflammation with 
oedema and deformity, the course of the disease, the general 
symptoms, the presence of the streptococcus erysipelatis, and 
a lesion of the surface, with a return of the tissues to a 
normal condition upon subsidence of the inflammation, are 



ERYSIPELAS. 



25 



characteristic. Diagnosis prior to the eruption is difficult or 
impossible. 

The differential diagnosis concerns chiefly the erythemata, 
drug-eruptions (antipyretics, copaiba), malignant pustule, and 
malignant oedema. 

Prognosis : Erysipelas is self-limited, and as a rule disap- 
pears leaying no trace. Healthy adults rarely die (Osier). 
Indiyiduals debilitated by age, disease, or the abuse of alcohol 
may succumb. In protracted cases death may be caused by 
exhaustion. Infection in the first months of life, usually 
occurring at the umbilicus, is very graye. Complications may 
increase the gravity of the prognosis. 

Prophylaxis : The streptococcus should be destroyed. To 
this end dressings, bedding, and clothing that come in contact 
with cases of erysipelas should be burned or thoroughly ster- 
ilized. Contaminated instruments and utensils should be 
boiled from five to ten minutes. The room and furniture, 
and all articles that cannot be subjected to the action of fire 
or steam, may be sterilized by the use of formaldehyde, solu- 
tol, or bichloride of mercury, or by prolonged exposure to 
fresh air. 

Erysipelas — treatment : Mild cases, in healthy adults, may 
require no treatment. The diet should be light and nutri- 
tious ; best milk, then soups, gruel, etc. Constipation may l)e 
relieved by calomel and Carlsbad salt. If necessary, the 
patient should be supported with alcohol. Otherwise internal 
medication has little effect upon the disease further than the 
relief of symptoms. Chloral may be given for nausea and 
vomiting. If the eyes are affected, the patient should be 
kept in a darkened room. 

In the way of local treatment, many cases do well Avith 
only wet compresses or inunctions. Active treatment seeks 
to destroy the streptococcus erysipelatis. Solutions of car- 
bolic acid (3-5 per cent.) or of bichloride of mercury (1 : 1000) 
are in common use. Carbolic acid, bichloride of mercury, and 
the biniodide of mercury may be used hypodermatically in 
2 per cent, solutions. The injections should be made just 
outside of the area of inflammation, where the streptococcus 
erysipelatis is to be found. Unfortunately, the injections may 



26 



INFECTIONS. 



not be used in the face, where the disease most frequently ap- 
pears. Strapping the surface with adhesive plaster has been 
reported to give good results, as does also the application of 
collodion and ichthyol. The employment of serum-therapy 
must be considered sub judice (see Septicaemia). 

CEREBRO-SPINAL MENINGITIS ( Epidemic Meningitis ; Lepto- 
meningitis ; Cerebro-spinal Fever ; Spotted Fever ; Malignant 
Purpuric Fever; Petechial Fever). 

Definition: An acute infectious disease, characterized by 
headache, hypersesthesia, opisthotonos, herpes, and petechise, 
and affections of the special senses. 

History : Cerebro-spinal meningitis was first accurately de- 
scribed by Vieusseux (Geneva, 1805). The disease appeared 
in the United States in 1806. Epidemics have been few. 
The disease is now pandemic ; but the cases being often ap- 
parently isolated, recognition of the disease is sometimes 
difficult. 

Etiology : The micro-organisms found in the exudate of 
cerebro-spinal meningitis are the diploco^cus intmcelhdaris 
menmgitidis (meningococcus) of Weichselbaum and the mioro- 
coccus pneumonke crouposce. These organisms are also pres- 
ent in the blood in some cases. The diplococcus intracellu- 
laris meningitidis is believed to be closely related to the 
micrococcus pneumoniae crouposce. These micro-organisms are 
sometimes associated with, or supplanted by, secondary infec- 
tion by the streptococcus pyogenes, staphylococcus pyogenes 
aureus, bacillus coli communis, the bacillus proteus, and rarely 
by other organisms. The avenue of entrance of the infec- 
tious agent is probably through the upper respiratory tract. 
Cold, crowding, and childhood are predisposing factors. 

Cerebro-spinal meningitis — symptomatology : The period of 
incubation lasts from eight to ten days (Latimer). 

The symptoms come on suddenly^ without prodromata, with 
chill, vomiting, headache, and prostration. Opisthotonos be- 
gins to show itself in stiffness of the back of the neck, with 
tenderness in the course of a few hours. There is hyperces- 
thesia, usually in the lower extremities, which may become 



CEREBR OS FIX A L MENINGITIS. 



27 



general. Various eruptions, including petechia, occur, but 
are not characteristic. Ucrpc^ may be observed as early as 
the third day, and cc^ntinue until after recovery, as a rule 
appearino' first about the face. The ieinpcfcttti re shows on 
early rise, 102" to 104° F., and an irregular course. The 
pulse is rapid, and later, with the temperature and respiration, 
shows great irregularity. Headache is persistent, and may be 
associated witli vertigo. Usually there is ronstij,(ifio)t. The 
jil)domen is boat-shaped. The urine is scanty, the bladder 
paretic. Bad cases show enuresis. The urine presents the 
diazo-reaction in severe cases. 

The blood presents the changes found in suppurative in- 
flammations. Leucocytosis is well marked during the active 
stage of the disease, and the amount of haemoglobin is usually 
diminished. Epistaxis is freqtiently observed. 

Complications : Pneumonia, catarrhal and croupous ; various 
pareses and jjaraJiises ; affections of the eye, photophobia, con- 
junctivitis, neuritis, atrophy of the optic nerve, blindness, 
keratitis with ulcer, iritis, irido-choroiditis, panophthalmitis, 
and amesthesia are the chief complications. Affections of 
the ear, suppuration of the middle and internal ear, perfora- 
tion of the membranes, deafness from inflammation of the 
labyrinth, are often present. Sometimes there is pleurisy, 
pericarditis, or parotitis. 

Cerebro-spinal meningitis — forms: (1) 31alir/nanf (foudroy- 
ant, siderant, fulminant, or apoplectic), in which death may 
take place in three and a half (Jewell) to thirty-six hours. 
(2j Abortive, including light cases, frequently unrecognized, 
in which convalescence begins after the symptoms have lasted 
from three to five days. (3) Intermittent, in which the inter- 
missions are not so regular as in malaria. The temperature 
bears a closer resemblance to the streptococcus-curve in some 
cases of septicaemia, which may show more or less periodicity. 
The usual duration is from one to three wrecks. (4) A chronic 
form has been described, which some believe to be the most 
frequent type (Heubner). Cases have been reported to last 
as long as fourteen weeks (AYorthington). In this form there 
is a series of recurrences of fever. 

Cerebro-spinal meningitis — morbid anatomy : Malignant 



28 



INFECTIONS. 



cases, if the patient die before exudation takes place, may 
present no cliaracteristic changes. Exudation is most abundant 
on the cortex. The membranes may be thickened and adher- 
ent. The spleen shows more or less enlargement, according 
to the duration of the disease. 

Diagnosis : The disease prefers winter, soldiers, and children 
(PfeiflPer). The diagnosis is usually easy when cerebro-spinal 
meningitis is epidemic. Cases of sudden death with symp- 
toms of profound toxaemia should excite suspicion of cere- 
bro-spinal meningitis in the malignant, foudroyant form. A 
sudden onset, with chill, and the presence of headache, opis- 
thotonos (often only rigidity of the muscles of the neck), and 
vomiting are characteristic. Sometimes most information is 
to be obtained by lumbar puncture (Quincke), which may 
reveal the specific cause of the disease. The disease should 
not be mistaken for tubercular meningitis, malaria, tetanus, 
hydrophobia, smallpox, or typhoid fever. 



Fig. 2. 




Contracture of the knee-joint in the position of flexion, nut 
admitting, without violence, extension beyond 135° with the 
thigh, while the patient is in the sitting posture, but which 
may be readily extended wiien the })atient is in the erect or 
recumbent posture, is characteristic of meningitis (Kernig). 
(Fig. 2.) 



BHEU3IATISM. 



29 



Prognosis : The mortality varies with the epidemic — 20 per 
cent, to 75 per cent. (Hirsch). Almost all malignant cases 
die. Abortive cases usually recover. The mortality in aver- 
age cases is about 50 per cent. The outlook in childhood is 
graver than in adolescence. Most of the deaths occur in the 
first week of the disease, especially during the first three or 
four days. The prognosis is not so favorable in protracted 
cases, although recovery is possible. 

Cerebro-spinal meningitis — treatment : The sick-room should 
be well ventilated ; light, noise, and unnecessary visitors must 
be excluded. The diet should be light and nutritious. It 
may be necessary to use forced feeding. The bladder and 
bowels call for proper attention. 

The chief remedy is opium, one grain every hour or two 
(Stille), which may be given to relieve pain and spasm, and 
to protect the nervous system against the action of the poison 
of the disease. Large quantities of opium may be given 
without producing toxic effects. In cases of vomiting inter- 
fering Avith the administration of opium, morphine may be 
given subcutaneously, gr. J- J for adults [v. Ziemssen). Later, 
cold (ice-bags) should be applied to the head and spine. Hot 
baths, 40° C, for ten minutes, give excellent results. 

Vomiting and hiccough may be relieved by the internal 
use of hot water, cracked ice, milk and lime-water, soda, creo- 
sote, bismuth, chloral, or by morphine hypodermatically. 
Chloral may be given by enemata, if necessary, to enable 
the patient to retain food. A failing heart calls for stimula- 
tion. Alcohol, best in the form of whiskey or brandy, is well 
borne. Bloodletting and blisters have their advocates. 

In extreme cases lumbar puncture or laminectomy and irri- 
gation are justifiable. 

RHEUMATISM. 

The term "rheumatism" [pebtia, psoj, to flow) has come 
down to us from the humoral pathologists. The term ca- 
tarrh,^^ which has the same derivation as rheumatism, with 
which it was synonymous, became confined to affections of 
the mucous membranes about the time of Ballonius (1600). 
" E-heumatism " became limited to diseases characterized by 



30 



INFECTIONS. 



pain about the bones, joints, and other structures than mucous 
membranes, which are not attributed to any special or specific 
cause. Later investigations have isolated gout, arthritis, 
trichinosis, syphilis, tuberculosis, and rickets. The term 
"rheumatism" is now used to cover at least five distinct affec- 
tions : 

Acute articular rheumatism, 

Chronic articular rheumatism, 

Gonorrhoeal rheumatism. 

Muscular rheumatism, and 

Nodular rheumatism (see Arthritis Deformans). 

Acute Articular Rheumatism. 

Definition : An acute infectious disease, characterized by 
multiple arthritis. 

Etiology : The disease is almost limited to the period of 
adolescence, fifteen to thirty-five years, and prefers fall and 
winter, when the weather is most changeable ; but no season 
is exempt. The disease is rare before four or after forty years. 
Individuals most frequently affected are those exposed to 
changes of temperature — drivers, servants, bakers, sailors, 
and laborers. The disease is frequently ascribed to taking 
''cold." Acute articular rheumatism often occurs in tlie 
course of the infections, especially scarlet fever, dysentery, and 
septicaemia (puerperal). The disease is believed to be due to 
some infectious agent, probably closely related to the strepto- 
coccus pyogenes. Often the infectious agent seems to gain 
entrance to the body through the tonsils. 

Symptomatology: The onset of the symptoms of acute ar- 
ticular rheumatism is often preceded by angina, especially 
to)isilifis, and iiialaise. Usually the disease begins suddenly 
with a cJiill and fever, reaching 102°-105° F. within a day. 
The pulse is usually above 100. There are more or less malaise 
and general distress. Affection of the joints is usually observed 
within the first twenty-four hours. The disease shows a prefer- 
ence for the me(Jivm-i<iz('(l joints^ especially the knee, ankle, and 
wrist ; later the shoulder and elbow, and still later the fingers, 
and the vertebral and sterno-clavicular joints. Rarely there 



RHEUMATISM. 



31 



may be involvement of the articulations of the maxilla, larynx, 
pelvis, and ribs. The joints become red and swollen. There 
may be subcataneous oedema. The disease flits from joint to 
joint, often to return again to a joint previously affected. 

There is profuse sweating, which lowers the temperature for 
a time. The perspiration is acid in reaction and sour-smell- 
ing. Often there are sudamina, especially in the absence of 
cleanliness. 

Examination of the blood reveals marked ancemia and 
leiicocytosis. The U7nne is usually reduced in quantity, con- 
centrated, of high color, acid in reaction, and loaded with 
urates. The chh)rides are diminished, and sometimes absent. 
The saliva may show an acid reaction and an excess of sui- 
phocyanides. 

Complications : The chief complication of acute articular 
rheumatism is usually on the part of the heart : pericarditis, 
endocarditis, or myocarditis. Some cases show hyperpyrexia, 
the temperature reaching 110°-! 18° F. Upon the part of the 
lungs there mav be pneumonia or pleurisy. Some cases show 
delirium and coma ; less frequently convulsions, rarely menin- 
gitis. Often there is chorea. The presence of sudamina has 
been mentioned. There may be a red miliary rash, scarlatini- 
form eruptions, purpura, often urticaria, and erythema. Rheu- 
matic nodules are sometimes found upon the tendons and 
fasciae. 

Diagnosis: The aflPection of medium-sized joints, and espe- 
cially the flitting from joint to joint, are characteristic points. 
Atypical cases and cases that do not respond readily to treat- 
ment should arouse the suspicion that they are not cases of 
rheumatism. Acute articular rheumatism must be separated 
especially from other forms of rheumatism, involvement of 
the joints in septicsemia, and gout and sarcoma. 

Prognosis: Rheumatism has, in itself, a mortality of about 
3 per cent. The remote effects are more dangerous. From 
one third to one-half of the cases have permanent heart- 
lesions. Sometimes the heart-lesions entirely disappear. 

Acute articula/r rheumatism — treatment : The patient should 
wear flannel and sleep between blankets. The best article of 
diet is milk, which may be diluted with alkaline mineral 



32 



INFECTIONS. 



waters. Thirst may be relieved by free ingestion of fluid. 
Often relief may be obtained by fixing the joint — sometimes 
simply by wrapping the affected joint in cotton or hot cloths. 
Various liniments may be used, and are of value chiefly 
through massage and the application of heat. 

Pain is sometimes relieved by the use of blisters or a 
light application of the Paquelin thermo-cautery. Salicin, 
salicylic acid, and the salicylates, for a time regarded as spe- 
cifics, relieve pain and probably neutralize toxins. The oil 
of wintergreen, TTLxx in milk every two hours, often gives 
good results. The salicylates are probably best given with 
alkalies, potassium or sodium bicarbonate or iodide, in suffi- 
cient dosage to render and keep the urine alkaline in reaction. 
Severe pain may demand opium, best in the form of Dover's 
powder, or morphine. As a rule, antipyrin, or better phen- 
acetin, salipyrin, or salophen will suffice. 

Excessive fever (hyperpyrexia) may be controlled best by 
the cold bath. Tumultuous action of the heart may be relieved 
by application of the ice-bag. 

Chronic Articular Rheumatism. 

Occurrence and symptoms : Only exceptionally chronic rheu- 
matism may result from acute rheumatism. Asa rule, chronic 
rheumatism comes on insidiously, after the meridian of life, 
and remains confined to the joint or joints first affected. The 
disease is found especially among the poor — those most ex- 
posed to cold and damp. The affected joint is somewhat 
swollen, stiff, and painful. The pain is increased during damp 
weather or upon exposure to cold and damp. The joint may 
become ankylosed. Chronic rheumatism shows a preference 
for the larger joints — hip, shoulder, knee, wrist, and ankle. 

Diagnosis : The age of the individual, the number of joints 
affiected, longer duration despite medication, and the absence 
of sweating, high fever, or complications on the part of the 
heart, are important points in diagnosis, and serve to diflPeren- 
tiate chronic from acute rheumatism. 

Prognosis : Life usually is not shortened ; but the outlook 
as to cure is not good. The disease is exceedingly obstinate 
to treatment. 



I 



RHEUMATISM. 



33 



I Chronic rheumatism — treatment: Iodide of potassium is 

' probably the best internal remedy. The salicylates may re- 
lieve the acute pain or exacerbations. Most may be accom- 
plished by the local application of heat and friction. All sorts 

f of liniments are recommended. Sometimes the use of blisters 

ji afPords relief. 

!' Often most may be accomplished by climato-therapy, espe- 
cially by prolonged residence in a warm climate, or at least 
by wintering in such a climate, to avoid cold, damp weather ; 

|l but few patients can afford such treatment. 

Gonorrhoeal Rheumatism. 

Gonorrhoeal rheumatism prefers the period of adolescence, 
the male sex, and the hiee-joint. There may be involvement 
of the ankle and joints of the foot. Usually the affection of 
the joints is observed within three months after the gonorrhoeal 
infection. The joints are greatly swollen. The specific cause 
is the gonococcus ; or the pyogenic micro-organisms, as a sec- 
ondary process (see Septicaemia). 

The disease runs a chronic course, does not show sweating 
nor involvement of the heart, and when finally cured does not 
return nor leave deformity. 

Treatment : Chronic gonorrhoea should receive attention, to 
prevent continuous infection. In the treatment of gonor- 
rhoeal rheumatism, most may be accomplished with heat, elec- 
tricity, friction, and massage. Further treatment is the same 
as for chronic rheumatism. 

Muscular Rheumatism — Myalgia. 

Etiology : Many cases are caused by trauma, whereby mus- 
cular fibres are ruptured. Other cases are attributed to cold 
and exposure, which probably act by localizing some infection 
or poison. At least one infection, that by the trichina spiralis, 
is now described separately under Trickinosis. 

Symptomatology : The only characteristic symptom is pain, 
which may vary in all degrees of severity and character, and 
is confined to the voluntary muscles. The pain is usually 7^e- 
lieved by pressure. 
3— P. M. 



34 



INFECTIONS. 



The chief varieties of muscular rheumatism are : occipito- 
frontal rheumatism ; torticollis, cervical rheumatism, stiff 
neck; pleurodynia, which is chiefly an intercostal rheuma- 
tism ; and lumbago, one of the most frequent and painful 
forms. Affection of the muscles of the head is sometimes 
known as cephalodynia. The pain may be localized in the 
muscles about the shoulder and upper part of the back — 
scapidodynia, omodynia, and dorsodynia. 

Diagnosis : Myalgia must be differentiated from the infec- 
tions, especially smallpox, tuberculosis, syphilis, and septicae- 
mia ; and aneurism, caries of bone, and tumors must be ex- 
cluded. The separation from neuralgia is sometimes difficult. 

Prognosis : Usually good. 

Treatment : The muscle should be put to rest — e. g., by 
strapping the chest with adhesive plaster in cases of pleuro- 
dynia. Heat, friction, and electricity are probably the best 
remedies. Pain may demand phenacetin, antipyrin, or mor- 
phine. Lumbago is sometimes relieved by acupuncture. Some 
cases may be cut short by a hot bath early in the course of 
the disease. In chronic cases iodide of potassium is the best 
single remedy. In all cases a careful search should be made 
for the cause, which should be removed or properly treated. 

INFLUENZA (Influenza (Italian, from influence) ; the G-rip ; La 
Grippe; Epidemic Catarrhal Fever; Chinese Catarrh (Rus- 
sian) ; the Russian Disease (German and Italian) ; Italian 
Fever, Spanish Fever (French)). 

Definition : An acute infectious disease, caused by the influ- 
enza bacillus, characterized by catarrhal symptoms on the part 
of the organs of respiration and digestion, and nervous symp- 
toms, especially prostration. 

Influenza — history : The disease was probably recognized 
by Hippocrates (Parks), and epidemics of this nature were 
recorded in the ninth century. In 1173 the disease seems 
to have been epidemic throughout Europe. The first accu- 
rate description is of the epidemic of 1510, when it is said 
scarcely a person escaped. The epidemic of 1557 spread west- 
ward from Asia to Europe and to America. The epidemic 
of 1647, which appeared first in Italy and France (1626-27), 



INFLUENZA. 



35 



is the first epidemic of the disease mentioned in American 
records (Noah Webster). Influenza is now pandemic, 
j Etiology : Tlie specific infectious agent is the influenza baeil- 
' his. This organism has been found in all cases of influenza 
examined, often in pure cultures in the bronchial secretion, 
^ frequently in the pus-corpuscles. In fatal cases it has pene- 
! trated into the peribronchial tissue and even to the pleura, 
where pure cultures have been found in the purulent exuda- 
tion. The influenza bacillus disappears, in cases of influenza, 
with the cessation of the purulent bronchial secretion. Pos- 
itive inoculation-experiments have been secured in apes and 
rabbits (Pfeiffer). The bacillus has been found in the blood. 
(Canon). Kaufman found the influenza bacillus in a large 
number of telephone-receivers examined. 

The influenza bacillus is aerobic, non -motile ; grows upon 
! glycerin-agar in the incubator, drop-like colonies developing 
in twenty-four hours, which are characteristic in that the 
drops do not cocdesce (Kitasato). The bacillus may be stained 
best with dilute carbol-fuchsin, or Loffler's methylene-blue so- 
lution with heat. The ends of the bacilli are most deeply 
stained, which probably at first caused them to be mistaken 
for cocci. The influenza bacillus prefers a soil containing 
hsemoglobin, and requires a temperature that liquefies gelatin. 

Influenza is highly contagious, and may be conveyed by 
fomites (clothing, third parties). Children seem somewhat 
less susceptible than adults. About one-fourth of cases occur 
I in early life. Influenza has been reported in infants only a 
' few days old, but is more frequent in the second half of the 
1 first year. The most susceptible period of childhood is from 
1 the eighth to the tenth year. 

I Influenza — symptomatology : The disease may show the 
usual prodromafa of infection : malaise, languor, headache, 
etc. The period of incubcdion varies from a few hours to 
four days. Usually the onset is sudden, with symptoms on 

; the part of the respircdory tract, the g astro-intestinal tract, and 

I the nervous system. 

The respiratory tract presents catarrhal symptoms, some 
fever, dryness, and swelling of the mucous membrane of the 
nose, increased secretion, and coryza. Often there is intense 



36 



INFECTIONS. 



bilateral bronchitis, and in children there is frequently pneu- 
monia. Influenza-pneumonia is an unfortunate complication. 
Photophobia and lachrymation are frequently present. 

On the part of the g astro-intestinal tract there are nausea, 
dyspepsia, vomiting, diarrhoea, and icterus, symptoms due to 
inflammation — catarrh — of the gastro-intestinal mucous mem- 
brane. 

The nervous symptoms are supposed to be largely caused by 
toxins. The spirits are depressed, the patient experiences 
sinking sensations, and there is prostration. Headache is a 
constant symptom, usually frontal — supraorbital neuralgia. 
There are pains in the back and legs and general soreness. 
There may be drowsiness and somnolence or insomnia. Ver- 
tigo may be persistent and severe. Rarely there is cerebro- 
spinal meningitis as a complication. Not infrequently tuber- 
culosis follows influenza, or is changed from a latent to an 
active process. 

Influenza — diagnosis : The respiratory, gastric, and nervous 
symptoms are characteristic. Symptoms on the part of the 
respiratory tract, the gastro-intestinal tract, or the nervous 
system may predominate in a given case or epidemic. In 
doubtful cases an attempt should be made to disclose the 
bacillus of influenza, which may be readily cultivated upon 
glycerin-agar in the incubating-oven. At the end of twenty- 
four hours small transparent drop-like colonies may be recog- 
nized, which are characteristic in that they do not coalesce. 

Prognosis : Death seldom occurs, except among the feeble, 
the aged, invalids, and young infants. The chief danger lies 
in the predisposition to other diseases, especially tuberculosis. 

Prophylaxis : If it were generally known by the laity that 

colds " are contagious, there would probably be fewer cases 
of influenza. Isolation of influenza-cases, to be of value, 
must be more complete than is usually practicable. The 
debilitated should not be exposed to infection. 

Influenza — treatment : The strength of the patient should 
be supported and individual symptoms met. The disease is 
self-limited ; but one attack does not secure immunity for any 
considerable length of time. 

Early in the course of the disease, especially when gastro=- 



WHOOPING-CO UGH, 



37 



intestinal symptoms predominate, calomel or the saline purga- 
tives may be used. A light " fever-diet " — milk, the gruels, 

I beef-tea— should be observed. Individuals previously weak- 
' ened by disease, age, or the abuse of alcohol may require the 

use of alcohol, whiskey, or brandy. In relief of symptoms, 
,j appeal may be made to the salicylates, salicylate of sodium, 
salol, best salipyrin, or the salicylate of cinchonidin, which 
causes less depression ; lactophenin, phenacetin, antipyrin ; 
morphine or opium, best in the form of Dover's powder. 

The oil of eucalyptus has been used, especially by the 
English. Flirst, in the treatment of children, claims good 
results from the local use of the vapor of turpentine and 
menthol. Benzonapthol has been highly recommended by 
Huchard in the gastric form of influenza, 5 mgr. (gr. ^) in 
pills, several times a day. Some advocate the use of quinine, 
gr. xv-xx, and others condemn its use. 

Excessive fever may call for hydrotherapy, the sponge- 
bath ; as a rule, however, hydrotherapy should not be used. 

WHOOPING-COUGH (Pertussis; Tussis Convulsiva; Keuchhus- 
ten, Kindhusten (German); Coqueluche (French); Tosse Ase- 
nine (Italian)). 

Definition : An acute infection, especially of childhood, 
characterized by paroxysms of convulsive cough, with usually 
a peculiar inspiratory " whoop,'' an inflammation of the nasal, 
laryngeal, and bronchial mucous membranes. 

History : At first not distinguished from bronchitis, influ- 
enza, and croup. Recognized by the Greeks (Mason Good). 

II Definitely described by Baillou (Paris, 1578). First mono- 
!l graph published by Danz (1791). 

Etiology: The catarrhal stage of whooping-cough is sup- 
posed to be due to the action of micro-organisms. The par- 
I oxysmal stage (whooping) is probably caused by the poison 
I (toxin) generated by the micro-organism. There is consider- 
( able evidence in favor of the bacillus discovered in the 
I sputum by Koplik, of New York, as the specific infectious 
I agent. The bacillus is about the size of the influenza ba- 
I cillus. 



i 



38 



INFECTIONS. 



Cohn and Neumann found in the sputum, at the end of a 
spasm, after washing with distilled water and staining with 
carbol-methylene-blue, diplococci and small chains of cocci. 
Ritter found the diplococcus tussis convulsiva in all of one 
hundred and forty-seven cases in which the sputum was ex- 
amined. This diplococcus resembles the gonococcus, but 
differs from that organism in that it grows upon agar (Schloss- 
man). Neumann could find the organism described by Ritter 
in only one out of eighteen cases examined. A similar organism 
has been described by Heubner as the intracellular meningo- 
coccus. Some observers hold that the cause is an amceba be- 
longing to the protozoa. Kurloff' found, in fresh, unstained 
sputum, amoebae with fine granular protoplasm, provided 
with cilia and showing active movement. Kurloff believes 
these to be the infectious agent of the disease, and that the 
bacteria, which he also observed, are probably concerned in 
the secondary affections and complications of whooping- 
cough. 

Contagion is usually by contact ; but may be through 
fomites, especially handkerchiefs. One attack usually confers 
immunity. The disease shows a preference for children, espe- 
cially the weakly, from six months to six years old. 

Whooping-cough — symptomatology : The period of incuba- 
tion varies from two days to two weeks. The symptoms of 
an acute catarrh of the air-passages then develop, and may 
last a few days or throughout the course of the disease. The 
paroxysm of cough is preceded by a distinct aura, which the 
patient soon learns to interpret as a forerunner of a spell of 
coughing. The cough is usually rew^arded by the discharge 
of a small quantity of mucus. Vomiting is common. Soon 
there comes the characteristic whoop an audible inspiration 
following a spasmodic cough. The ''^ whoop " is heard at the 
close of a series of coughs. 

Gilbert recommends recording on a chart the coughing- 
spells, in suspicious cases. The duration of the paroxyms is 
noted, and also the length of time between paroxysms. There 
is a coughing-spell about once every hour in the daytime, and 
every half hour at night. The paroxysms consist of six or 
eight coughs, " beginning with a big, loud cough, and tapering 



WHOOPING-CO UGH. 



39 



down to a mere ' hack/ " Gilbert represents the whooping- 
cough diagramatically thus : 

C CCCcc C CCCcc — C CCCc etc. 

The cough of simple bronchitis may be represented thus : 

c-c-c-c-cc-c-c-c-c-c - ccc - c- c- c- c-cc. 

In this way Gilbert claims to be able to make a diagnosis in 
the first week of whooping-cough, before the characteristic 
whoop is heard. 

An ulcer may frequently be found upon the frenum of the 
tongue, due to friction against the lower incisors. Sometimes 
the ulcer is found in the absence of whooping-cough, and it 
may be absent in cases of whooping-cough. 

The paroxysmal stage continues usually two to six weeks. 
The severity of the symptoms begins to diminish, as indicated 
by fewer paroxysms, and after ten days to several months 
health is restored. 

Complications : The most frequent complication of whoop- 
ing-cough is broncho-jmeumonia. Less frequent is emphysema. 
Petechia, especially upon the forehead, ecchymosis of the con- 
junctivae, epistaxis, and hgemoptysis may occur. Albuminuria 
may be found, but serious kidney-lesions are not common. 

Diagnosis : The history of exposure is often of value. The 
cough not only persists, but increases despite treatment. The 
whoop is characteristic. Gilbert claims to be able to make 
the diagQOsis by the character of the cough (see Symptomat- 
ology), even in the absence of the " whoop." There is evi- 
dence of inflammation of the nasal, laryngeal, and bronchial 
mucous membranes. An ulcer on the frenum of the tongue, 
the result of friction against the lower teeth, may usually be 
found, but is not pathognomonic. In doubtful cases measles may 
be excluded if there be no eruption by the fifth day. Whoop- 
ing-cough often occurs during convalescence from measles. 

Prognosis : The prognosis is usually favorable ; not so good 
in the debilitated or in the negro race. Frequently tubercu- 
losis has been observed to follow whooping-cough. 

Prophylaxis : The patient should be isolated. Isolation is 



40 



INFECTIONS. 



difficult to secure in mild cases. At any rate, invalids and 
delicate children must not be exposed to contagion. The 
sputum should be destroyed. 

"Whooping-cough — treatment : Mild eases may call for no 
treatment. Often it is only necessary to treat the associated 
catarrh. For the paroxysms a number of remedies have been 
recommended. Should the paroxysms not exceed half a 
dozen per day special treatment may not be necessary. 
Where the paroxysms are troublesome antipyrin, gr. ij-iij 
for a child two years of age, often acts very well. Acetanilid, 
phenacetin, and lactophenin may be used in individual cases. 
Bromoform, gtt. ij-iv three or four times a day for a child 
three to six years of age, on sugar or in alcohol, has many 
advocates. Belladonna, from two minums of the tincture or 
gr. -^-^ of the extract up to tolerance, given three or four times 
a day at two years of age, has stood the test of time. Qui- 
nine, gr. j or more, every two or four hours, for a child two 
years old, is largely used. Opium (paregoric) relieves the 
cough, secures sleep, and protects the nervous system. Chlo- 
ral may be given to relieve vomiting and secure sleep. A 
change of climate sometimes becomes necessary. 

Raubitschek attempted to determine whether or not whoop- 
ing-cough is due to bacteria, by the local application of bi- 
chloride of mercury, 1 : 1000, to the tonsils, uvula, epi- 
glottis, and adjacent mucous membrane. The application was 
made every day in severe cases, and every other day in mild 
cases. As a rule, improvement was noticed on the second or 
third day. In the paroxysmal stage the disease disappeared 
after four or five treatments. 

Naegely advises grasping the hyoid bone, over the two 
greater cornua, and the larynx, and holding them from sixty 
to ninety seconds, as a means of cutting short the paroxysms. 
He believes the action is due to the induction of an inhibitory 
reflex. 

Eothschild found the faithful use of tussol from the begin- 
ning of the disease caused the whooping-cough to be milder 
and shorter in duration. Some cases recovered in two weeks. 

Koroleff found the disease entirely disappeared in three 
days in four cases treated with naphthalin vapor; while in five 



MUMPS. 



41 



other cases, treated in the same way, the course of the disease 
was unaffected. 

Neumann used benzine vapor with good results ; but found 
little value from the use of chloroform by inhalation. Reh- 
feld, on the other hand, used chloroform anaesthesia in a case 
of whooping-cough while setting a broken thigh-bone, and 
there was an immediate disappearance of the whoopiug-cough. 

Mohn found the inhalation of sulphur fumes was followed 
by a reduction of the duration of the disease to eight to four- 
teen days. The sleeping-room was charged with sulphur 
fumes. Two or three treatments were sufficient. 

Topical applications secure l^etter results than inhalations. 
Bichloride of mercury solution, 1 : 1000, never fails to arrest 
the disease (Raubitschek, Gentile, Fede). 

Oliphant secured good results from the local application of 
formalin. 

Ditel uses the bromides during the paroxysmal stage, fol- 
lowed in a few days by the use of codein. For the fever 
Ditel uses antipyrin, and for the bronchitis terpin hydrate. 

Binz recommended the use of quinine. The remedy may 
be used per rectum. Unruh advises the insufflation of quinine 
into the nose and pharynx. 

Celli found vaccination sometimes followed by a cessation of 
whooping-cough. Bolognini believes vaccination justifiable as a 
therapeutic measure in children that have not been vaccinated. 

In cases complicated by broncho-pneumonia, when many of 
the remedies usually employed in whooping-cough are contra- 
indicated, the use of camphor has been advised. 

Good results may be secured in bad cases by the use of 
resorcin, 2 to 3 per cent, solution, applied locally. 

The patient should be in the open air as much as possible. 
Thorough ventilation of the apartments should be secured, 
even in cold weather. 

MUMPS (Epidemic Parotiditis; Epidemic Parotitis; Mompen 
(Danish) ; Schafskopf, Ziegenpeter (German) ; Oreillons 
(French)). 

Definition : An acute, infectious, contagious, epidemic dis- 
ease, characterized by inflammation of the parotid gland, often 



42 



INFECTIONS. 



complicated by involvement of the testicle in the male ; and 
of the breast, ovaries, and external genitals in the female. 

History : Mumps was recognized in the earliest times. The 
disease was described by Hippocrates. 

Etiology : Many observers have cultivated micro-organisms 
found in cases of mumps. Michaelis found diplococci resem- 
bling the gonococcus and meningococcus, but smaller. Inocu- 
lation-experiments have not succeeded in producing the dis- 
ease. 

Infection probably occurs through the duct of Steno. Most 
cases are preceded by, or associated with, inflammation of the 
mucous membrane of the mouth or throat. The epidemic 
nature of mumps is well known. Contagion usually requires 
close contact, although infection may be carried by third par- 
ties (fomites). Mumps show preference for the period of 
childhood and early adolescence, especially from the fifth to the 
fifteenth years. The disease seldom appears under two years ; 
age is almost exempt. It has been suggested (Soltmann) that 
the exemption of infancy and age may be attributed to the 
duct of Steno being small in infancy and atrophied in age. 
The exemption of age may be largely due to the exhaustion 
of susceptible material, few reaching advanced age without 
protection by previous attack. 

Males are attacked more frequently than females. Mumps 
prevails especially during the cold months. The disease may 
affect animals (dogs). 

Mumps — symptomatology : Incubation may be as short as 
three days (Leitzen), or as long as six weeks (Nicholson) ; 
usually about two weeks. This period presents no symptoms, 
at least no characteristic symptoms, of the disease. Prodromal 
symptoms of infection, — malaise, headache, neuralgic pains, 
anorexia, slight fever, less frequently diarrhoea, vomiting, con- 
vulsions, — are present in about one-third of cases (Rilliet and 
Barthez). These symptoms last from a few hours to a few 
days, usually two to eight days. 

AVith the onset there is usually a chill or chilly sensations ; 
then fever, as a rule 101 ° F. or less, reaching during the course 
of the disease 102° F., exceptionally as high as 104° F. 

Evidence of affection of the parotid gland is one of the 



MUMPS. 



43 



earliest and most characteristic symptoms. Usually there is 
]jai}i in one of the parotids. The gland soon begins to sivell ; 
the swelling becomes extensive, causes the ear to be displaced 
upward, outward, and forward, and may cause the head to 
lean to one side. As a rule, the infection extends to involve 
both parotids. Often there is involvement of the testicle — 
orchitis — in the male. In females affection of the breast — 
mastitis — is common, also of the external genitalia, rarely of 
the ovaries, oophoritis. Sometimes the attack is announced 
by otalgia, especially in children (Comby). 

Complications are rare. Affection of the labyrinth may 
cause deafness. Other complications, especially on the part of 
the brainy may be caused by interference with the circulation 
or by toxcemia. 

Mumps — diagnosis : The presence of an epidemic is an aid 
in diagnosis, which is usually easy. The onset of the disease 
with enlargement of the parotid, indicated by swelling at the 
angle of the jatv and with displacement of the ear, sometimes 
of the head, with pai??, tenderness, and more or less fever, 
characterizes the disease. In some cases, such as those marked 
only by orchitis without the development of other symptoms 
of mumps, an absolute diagnosis may be difficult or impossi- 
ble. 

Prognosis : As a rule, good. Uncomplicated cases do not 
die. According to Laveran, the chief danger in the adult 
male is orchitis, which occurs in about two-thirds of the cases, 
and results in atrophy seven times out of ten. Thus impo- 
tence may follow double orchitis, which, however, is rare. 
Other unfortunate complications are mastitis, nephritis, otitis, 
and permanent deafness. 

Mumps — prophylaxis : This calls for isolation, three weeks 
to a month, and disinfection (steam, formaldehyd) of the sick- 
room and of all articles which come in contact with the pa- 
tient. Prophylaxis is exceedingly difficult, vsince the disease 
is often so mild in character, and since it may be disseminated 
during the period of incubation and for some time after the 
disappearance of symptoms. 

Mumps — treatment : The treatment is symptomatic. The 
patient should be kept in the house, in bed, if the fever 



44 



INFECTIONS. 



is high. Sometimes aconite is given for fever. The diet 
should be fluid or such as may be swallowed without dis- 
tress. The tension caused by the enlargement of the parotid 
may be relieved by hot or cold applications, as the patient 
may prefer, usually best by hot poultices, lard, vaseline, olive 
oil, or cocoa-butter. Gargles, as with hot salt water, are of 
very great value. If orchitis develop, the testicle must be 
supported, and later treated with the faradic current. The 
bowels should be kept open, best with a saline laxative or 
calomel. Often the patient may be made more comfortable 
by the use of Dover's powder or phenacetin. 
Coriiplications must be met by special treatment. 

MEASLES : Morbilli (Italian) ; Rubeola (Sauvages) ; Rougeole, 
Ruber (French); Masern (German); Masura (Sanscrit)). 

Definition : A very contagious acute infection, characterized 
by early catarrhal symptoms, coryza, and bronchitis, and later 
by a peculiar eruption. 

Etiology : Doehle (1891) described bodies resembling proto- 
zoa in eight cases of measles. The observation lacks con- 
firmation ; but many believe that measles, scarlet fever, and 
smallpox may be due to organisms of this character. Canon 
and Pielicke (Berlin, 1892) discovered a short, thin bacillus 
in the blood of measles patients in fifty-six cases. The bacil- 
lus varies from 0.5 /j. to the diameter of a red blood-corpuscle 
in length, and in culture is found in long threads. The dis- 
covery has been confirmed by some observers (Czajkowski, 
Grigorieff ), while others (Barbier, Warschovsky) have failed 
to find the bacillus in cases of measles. Some observers be- 
lieve the cause is a micro-organism that is too small to be recog- 
nized by the strongest known power of the microscope. 

Measles shows a preference for winter and spring. The dis- 
ease is very contagious, which explains the apparent liability 
of childhood, especially from one to five years. Comparative 
exemption of the first six months of life is probably due to 
freedom from exposure to infection. Individuals in later life 
are protected largely by previous attack. The children of 
mothers with measles show marked exemption from the dis- 
ease. 



MEASLES. 



45 



Measles may be communicated through the nasal secretion, 
which explains the general belief that measles is contagious 
J through the breath. The disease may be conveyed by third 
parties, clothing, etc. Measles is contagious throughout its 
course ; probably during incubation, certainly during the pro- 
dromal stage. 

Measles — symptoms : The period of incubation lasts from 
seven to eighteen days, during which there are no symptoms 
characteristic of the disease. Inoculation-experiments have 
placed the incubation at ten days. The eruption appears 
about two weeks after exposure. 

Invasion: The patient has a shivering fit, possibly a chill. 
At this time there may be no noticeable fever, but soon the 
temperature rises to 100'^-104° F., with symptoms on the 
I part of the stomach and nervous system. There is inflamma- 
tion of the mucous membrane of the eyes, nose, pharynx, and 
larynx, with severe coryza, cough, and photophobia. The 
mucous membrane of the cheeks is swollen to show the im- 
print of the teeth. There is bronchitis. 

Usually during the second day the eruption appears, first 
as an enanthem upon the mucous membrane of the mouth, 
from one to five days before the exanthem appears on the 
skin. The former reaches its height just as the eruption 
on the skin is appearing, and then fades. Koplik describes 
I the enanthem as minute bluish-white specks on a reddish 
! punctuate area in beginning measles, and on a more diffused 
background in advanced cases. Microscopic examination 
j of the spots reveals diplococci and epithelial cells. This 
I enanthem is believed to be pathognomonic of measles. The 
breath has the odor of sour paste. The patient suffers gen- 
eral malaise and thirst. In some cases, especially in certain 
epidemics, dulness and somnolence appear among the prodro- 
mata. 

From the third to the fifth day, usually about the fourth day, 
the exanthem appears, as a rule, first on the forehead, at the edge 
of the scalp, or behind the ears ; later, around the eyes and 

(mouth, and on the chin and neck. The eruption may be at 
first red and punctiform, or only a diffuse redness ; but in a 
few hours small rounded red spots appear, separated by ap- 



46 



INFECTIONS. 



parently healthy skin. At first the spots disappear on press- 
ure, to reappear when the pressure is removed. Later the 
spots no longer disappear on pressure. 

The ei'uption gradually spreads from the forehead and 
sides of the face downward over the trunk and upper ex- 
tremities by the seventh day, and over the lower extremities 
by the eighth day. Within about twenty-four hours after the 
first appearance of the exanthem, the eruption begins to dis- 
appear. Thus the eruption may vanish from the face before 
it appears on the lower limbs. With the disappearance of 
the eruption there is an improvement in the general symp- 
toms, usually with a return to health in ten to fourteen days. 
After the eruption there is a desquamation, usually fine and 
branny. Desquamation is sometimes absent, especially in 
light cases. 

In the absence of complications, an average case of measles 
presents approximately ten to fourteen days' incubation, three 
days' invasion, three days' progress, and three days' decline. 

Measles — forms : In severe cases, rubeola sidemns, the indi- 
vidual may be overwhelmed with the poison of the disease 
and die during the stage of invasion. On the other hand, in 
very light cases the patient may show little evidence of ill- 
ness. Almost any of the symptoms may be present or absent 
in a given case. Thus there may be none of the symptoms 
of catarrh, rubeola sine catarrho ; the eruption may be absent, 
rubeola sine eruptione, although probably some eruption is 
present in every case ; or there may be little or no fever, 
rubeola afebrilis. 

Hemorrhage may take place under the skin or from the 
mucous membrane of the urethra, vagina, nose, intestine, and 
other mucous membranes, or into the muscles and serous 
membranes, rubeola nigra, black measles. Such cases rarely 
occur in private practice, but may be found under bad hygienic 
surroundings. 

The more important complications and sequelae of measles 
are : bronchitis, broncho-pneumonia, croupous pneumonia, 
catarrhal pneumonia, tuberculosis, pleurisy, stomatitis, noma, 
laryngeal stenosis, diphtheria, enterocolitis, endocarditis, peri- 
carditis, /iea(iac/^e, convidsions (es^ecmWy in children), delirium. 



MEASLES. 



47 



tubercular rueningitis, paralyses, chronic conjunctivitis, iritis, 
blepharitis, keratitis, catarrhal or purulent otitis, and nephritis. 

Measles — diagnosis : Diagnosis is usually impossible during 
the period of invasion, and is often very difficult during the 
prodromal stage of the disease. The absence of previous 
attack and the presence of other cases of the disease may aid 
in some cases. 

In measles there is a long prodromal stage, with fever and 
catarrh^ and later a peculiar eruption. The spots described 
by Koplik in the enanthem (see Symptomatology), are of 
especial value in the differentiation of measles from scarlet 
fever, simple aphthse, rubella, and influenza. One of the 
most characteristic signs is the early photophobia, which is 
often of value in the differentiation from influenza. 

Measles should be differentiated, especially from simple 
catarrh or coryza, hay-fever, scarlet fever, rubella, variola, 
typhus, roseola, papular erythema, and drug-eruptions (co- 
paiba, quinine, antipyretics). 

Prognosis : The prognosis of measles would be excellent if 
it Avere not for the complications and sequelae of the disease. 
Should the temperature continue high after the appearance 
of the eruption on the fourth or fifth day, complications may 
be expected. The most dangerous of these is tuberculosis, 
which is often changed from latent to active. Bronchitis and 
pneumonia are responsible for many deaths. 

Prophylaxis : One of the chief difficulties in prophylaxis is 
the fact that measles is contagious before the appearance of 
characteristic symptoms. The child should be isolated upon 
the first suspicion of the disease. Widowitz believes that 
epidemics of measles could be prevented by closing the school- 
room in which the first case occurs, from the ninth to the 
fourteenth day after the first appearance of symptoms, during 
which time all children from the room should be isolated 
from other children. The children could then return to 
school upon presenting the certificate of a physician. The 
disease may be carried by third parties and things (fomites). 
Quarantine should be continued two or three weeks after the 
onset of symptoms. The patient should then receive a bath 
and put on clean clothing. The room, and all articles which 



48 



INFECTIONS. 



have come in contact with the patient, should be sterilized. 
As a rule, exposure to fresh air is sufficient to destroy the con- 
tagious principle of measles. 

Measles — treatment : The subcutaneous injection of serum 
obtained from convalescents from measles has been practised 
by a number of observers (H. Thompson, Weisbecker, Hubert, 
Bhunenthal), with results more or less encouraging. Weis- 
becker injected serum, obtained from a convalescent, into a 
child nine months old, showing the prodromal stage of measles 
and whose brothers and sisters were taken with the disease. 
Ten grammes of serum were injected, with the result that the 
eruption was confined to certain parts. In four cases of 
pneumonia following measles two cases received the same 
dose, ten grammes, and the other two twelve and eighteen 
grammes. In each of these cases resolution occurred in a few 
days. In two of the cases there was a rapid disappearance of 
the fever ; in six hours in one case ; in twenty-four hours in 
the other. 

The use of the serum of convalescents is believed to confer 
immunity, to cause the disease to run a milder course, to 
shorten the duration of illness, and even to cause a rapid 
disappearance of general symptoms. 

Distressing symptoms or complications should be met, and 
the patient placed under good hygienic surroundings and sup- 
ported until the disease has run its course. Mild cases may 
call only for the relief of thirst, cough, and photo])hobia. 
Thirst may be relieved by water, simple or acidulated, lemon- 
ade, or raspberry vinegar. Milk is the best food, diluted 
with water, soda-water, mineral water. Cough may be con- 
trolled by codein or small doses of Dover's powder. Laryn- 
gitis, stomatitis, and pharyngitis may be treated with antiseptic 
solutions. Severe laryngitis may call for the application of 
hot fomentations to the front of the neck. In membranous 
laryngitis, intubation, or tracheotomy is sometimes necessary. 
Bronchitis may call for expectorants, best apomorphin. Pho- 
tophobia is relieved by shading the eyes with smoked glasses 
or screens, and the irritation may be reduced by the local 
application of solutions of morphine or atropine. The edges 
of the lids should be anointed with vaseline to prevent them 



RUBELLA. 



49 



adhering during sleep. Earache is relieved by the evapora- 
tion of chloroform near the meatus, or by the instillation of 
hot water or a grain-to-the-ounce solution of atropine. Slight 
1 fever may be disregarded; fever above 103° F. may be met 
■ with the warm bath or, though more unpleasant, the cold bath 
I (F(xlor, Dieulafoy). The desired result may often be obtained 
by the use of antipyrin, phenacetin, and similar remedies in 
!i small doses, with beneficial elFect upon the nervous symptoms 
j so often present. Xervous symptoms may call for the bro- 
!j mides; sleeplessness, for trional, chloral. Diarrhoea may be 
I controlled by bismuth and opium. Constipation should be 
carefully treated to avoid diarrhoea, best by enemata, some- 
:imes by small doses of castor-oil or calomel. 

RUBELLA Eotheln; German Measles; French Measles). 

Definition : A contagious acute infection of short duration, 
presenting mild catarrhal symptoms and a characteristic erup- 
tion. 

Etiology : Rubella occurs especially at from five to fifteen years 
: f age, although adults are often attacked. Previous attacks 
of measles or scarlet fever do not protect against rubella. 
Micro-organisms have been found in the blood (Klamann, 
Edwards), but have not been proven to be the cause of the 
disease. 

Eubella — symptoms : Incubation lasts from five days to 
\ three weeks, probably the most variable of any of the acute 
i infectious diseases. The prodromal stage is short, one-half 
[ to one day, often scarcely perceptible. During this period 
f there may be some symptoms of inflammation of the mucous 
i membrane of the respiratory tract, some malaise, headache, 
vomiting, diarrhoea, or constipation ; but as a rule these symp- 
toms are not marked. Often the period of eruption sets in 
without previous symptoms. 

Forchheimer attaches importance to the enanthem of rubella, 
which he believes to be present in all cases as a macular, 
distinctly rose-reol eruption upon the velum of the palate and 
ovula, extending to, but not onto, the harol palate. The spots 
are arranged irregularly, not crescentically, are the size of 



60 



INFECTIONS. 



large pinheads, at the largest, and are very little elevated 
above the level of tlie mucous membrane. During the process 
of involution, especially in mouths liaving a pale mucous 
membrane, there are sometimes left pigmented deposits, 
usually of a yellowish-brown color, in spots or streaks. 

The eruption extends from the face to the feet in a day. 
The eruption of rubella may resemble the eruption of measles 
or of scarlatina — rubella morbillosa, rubella scarlatinosa. The 
eruption may fade from one part before attacking another 
part, or it may cover the entire body at one time. The color 
is usually a pale red. The maculce are more or less elevated, 
smaller, and not arranged in groups as in measles. The red 
points seen in scarlatina are absent in rubella. The erup- 
tion lasts at the longest only three or four days. There is 
little or no fever. Desquamation may be absent, and Avhen 
present is slight and resembles that of measles. Complica- 
tions are rare. 

Diagnosis : Rubella is distinguished by its mildness, the 
absence or slightness of prodromata and fever, the enanthem, 
the diffuse rose-red irish, and the enlargement of the cervical 
lymphatics early in the course of the disease. 

Rubella should be differentiated especially from measles, 
scarlatina, syphilis, and drug-eruption. 

Prognosis : Excellent. 

Prophylaxis calls for isolation. 

Treatment: Little or no treatment is required. Usually it 
is difficult even to keep the child in bed. Any unpleasant 
symptoms should be treated symptomatically. 

SCARLET FEVER (Scarlatina ; Scharlach (German) ; Scarlatine 
(French] ; Scarlatto (Italian)). 

Definition : An acute, highly infectious disease, exhibiting 
a peculiar rash, angina, and fever. 

Etiology : Scarlet fever is generally believed to be due to 
some micro-organism, probably a coccus — micrococcus, strepto- 
coccus, diplococcus — but as yet this has not been proven. 
Many observers would attribute the failure to find the specific 
infectious agent to the limited magnifying power of the micro- 
scope. The pus-formers are commonly present in the local 



SCARLET FEVER. 



51 



inflammatorv processes, in the exudate in the throat, and in 
secondary alfections and suppurations. A denuded surjace, 
sore tiiroat, Avound, the puerperium, predispose to infection. 
Scarlet fever may be conveyed directly or by third parties, 
clothing, milk, mail (fomites). The vast majority of cases 
occur nnder the age of ten years. Liability to attack is greatest 
at five years ; the greatest mortality is at three (Gresswell). 
The disease has been observed as early as the second day of 
life (Cortes). The geographical distribution and the indi- 
vidual susceptibility are less in scarlet fever than in measles 
and smallpox. One attack confers immunity. 

Fleming believes scarlet fever to be a local disease of the 
throat, and that the nephritis and dermatitis result from the 
attempt at excretion of the toxin. 

Behle, of Frankfort, in a district in which pigs' scarla- 
tina'' (English) — Rothlauf (German), Rouget (French) — had 
been previously unknown, found a severe epidemic of scarlet 
fever among children followed or accompanied by a disease 
among tl^e pigs, marked by the symptoms of scarlet fever, 
including erythema, angina, albuminuria, and ursemia. Death 
in these cases was usually due to uraemia or angina. Charac- 
teristic lesions were found post-mortem in the kidneys. A 
previously healthy pig inoculated w^ith the blood of a child 
suffering from severe scarlet fever, died a week later, and 
presented symptoms and post-mortem appearances identical 
with those of scarlet fever in man and the disease present 
in the other animals. The animals had probably been 
infected from children or from one another. 

Scarlet fever — symptomatology : Incubeition lasts from one 
day to one wxek. The period of invasion, lasting one or two 
days, usually sets in suddenly. As a rule, there are chilly 
.s-en-s-af/otts rather than a true chill. Fever ( Fig. 4) often reaches 
104° or 105° F. on the first day, with pall()r and prostration. 
Frequently there is vomiting early in the course of the disease, 
and convvlsions, especially in young children. The skin is 
dry and the tongue furred. Even on the first day there may 
be some dryness of the throat ; inspection soon reveals the 
characteristic angina. Cough and catarrhal symptoms are not 
common. 



52 



INFECTIONS. 



The enanthem is found first, as a rule, upon the anterior , 

pillars of the fauces, the uvula, and the palate, possibly extend- ' 

ing over the mucous membrane of the cheeks and gums upward ' 
into the nose. The enanthem disappears much in the same 

way as it appears, by desquamation, leaving a coating that t 



Fig. 3. 



DAY OF 
OiSEASE 


1 


2 


3 


4 


5 


G 


7 


104 


M E 


M E 


M E 


M E 


M E 


M E 


M E 












































102° 






























lOI^ 


\ 




























100" 

99° 

NORM'L 

-^8- 








1 





































Initial fever. Eruption. 

Temperature in measles. 
Fig. 4. 



DISEASE 1 2 3 4 5 



105 

104" 
103° 

102*^ 
lOI^ 

100'^ 



9 10 11 12 1.3 14 



99 

NORM'L 
TEMP., 
•—98^ 

Er'.iption. 

Temperature in scarlet fever. 
A comparison of the temperature in Scarlet Fever and Measles. 



may be confused with that of diphtheria. Usually the enan- 
them is at its height when the exanthem appears. 

The exanthem appears on the first or second day, usually 
first on the neck, chest, and back, especially in the region of 
the clavicles, and may spread over the body within forty- eight 
hours. The mouth is usually spared. The color of the erup- 
tion is lighter than that of measles — a scarlet — which has 



SCARLET FEVER. 



53 



! given the name to the disease. The eruption disappears from 
i the face, neck, chest, and body within a week — four to six 
I days — with desquamation, frequently in the form of casts, espe- 
! cially of the hands and feet. The appearance of the swollen 
papillae protruding through the white coating of the tongue 
has given rise to the term, strawberry ^\ tongue. This may 
be found in other conditions. The sore throat varies greatly 
I in intensity in different cases. 

] Scarlet fever — complications : Nephritis is the most impor- 

I tant complication, and is much more frequent in some epidem- 
ics than in others. Albuminuria early in the disease may be 
due to the accompanying fever; but later, from the second to 

I the fourth week, may indicate acute nephritis, which causes 
oedema, especially puflfiness of the eyes, nervous symptoms, 
neuralgia, headache, vertigo, insomnia, convulsions, coma, 

' through the effect of irritant products upon the nervous 
system. Affection of the ear is common, and may extend to 
cause meningitis. Joint- affect ions are sometimes present, 
probably through secondary infection. 

Scarlet fever — forms : The symptoms are sometimes very 
light and the course of the disease short, constituting the 
abortive form of scarlet fever. The eruption of scarlet fever 
sometimes remains loccdized, beino; found onlv in the face 
(Braun, Lemoine). Such cases may pass unrecognized and 
convey the disease. Sometimes the poison is so intense as to 
take life during the period of invasion, the fulminant form ; 
or the symptoms may be exceedingly severe, the malignant 
form. The angina may assume special prominence, the 
anginose form. 

Scarlet fever — diagnosis : The presence of an epidemic, the 
history of exposure, and of absence of previous attack may aid 
in the individual case. 

The sudden onset of the disease, often with vomiting, one 
day to one week after exposure; the peculiar angina; the 
characteristic eruption on the first or second day ; the ^' straio- 
berry " tongue, later the desquamation, " casts," especially of 
the hands and feet, and the complications on the part of the 
Iddneys, ear, and joints, mark the disease. 

Scarlet fever should be differentiated especially from diph- 



54 



INFECTIONS. 



tberia, measles, rubella, septicaemia, acute exfoliating dermati- 
tis, and drug-rashes (belladonna, quinine, iodide of potassium). 

Scarlet fever — prognosis : The prognosis varies greatly in 
different epidemics, 3 per cent. (Hirsch) to 90 per cent. (Johan- 
nessen). A mortality of 10 to 13 per cent, is considered 
normal, although in private practice the rate is not so high. 

The prognosis in the individual case depends upon the 
nature of the prevailing epidemic, the character of the infec- 
tion, and the existing complications. Fulminant and malig- 
nant forms always give a grave prognosis. Recovery from 
nephritis is the rule in scarlet fever. Persistent anuria is 
ominous. Early in the course of scarlet fever severe nervous 
symptoms would point to a bad prognosis. Should complica- 
tions cause the eruption to disappear, to be driven in," the 
mortality is increased. An unusually high or low tempera- 
ture is to be looked upon with suspicion. Other complica- 
tions that increase the danger of scarlet fever are : severe 
inflammations about the neck, phlegmonous processes, oedema 
of the glottis, pneumonia, pleurisy, peritonitis, endocarditis, 
pericarditis, and meningitis. 

Prophylaxis: Isolation of the patient should be absolute. 
Scarlet fever may be conveyed by contact, either direct or in- 
direct, through tliird persons, clothing, dishes (fomites). Sus- 
ceptible children should !)e sent away from a house in which 
there is scarlet fever. Children who are nursing women sick 
with scarlet fever rarely contract the disease, and then usually 
only in a mild form. In all cases quarantine should be con- 
tinued until desquamation is complete. A collective investi- 
gation in English hospitals showed the minimum duration 
of the infectious period of scarlet fev^er to be eight and the 
maximum thirteen wrecks. The sick-room should be kept 
well ventilated, and the patient should be bathed frequently. 
After recovery is complete the patient should receive a full- 
length bath and a change of clothing. The sick-room and 
all articles with which the patient came in contact must be 
disinfected or destroyed l)y fire. The nasal mucous mem- 
brane should be thoroughly cleansed before the case is dis- 
charged. 

Gonzales reports good results from the prophylactic use of . 



SCARLET FEVER. 



55 



sodium snlphocarbolate, where isolation was incomplete or 
not practised, and claims to have prevented contagion in sev- 
enteen families, protecting one hundred and thirty-nine chil- 
i dren exposed to scarlet fever. 

i Scarlet fever — treatment: Good results have been secured 
' by the injection of the blood of recent convalescents ; but 
such treatment is not generally practicable. 

The patient should be placed under good hygienic sur- 
roundings, in a room where thorough ventilation may be se- 
cured and an equable temperature maintained, 65° to 70° F. 
at the head of the bed. The patient must be kept abed. The 
best single article of diet is milk. The meat soups afford an 
agreeable change. Acidulated, mineral, or plain pure water 
should be offered at regular intervals. A daily full-length 
i warm bath contributes to both cleanliness and comfort. Tem- 
' perature over 103° F. calls for the application of cold, spong- 
ing with cold water, the use of the cold pack, or the cold 
bath. It is more comfortable to the patient not to have the 
bath too cold ; or, to have the temperature of the water re- 
duced gradually after entering the tub. The bath may be 
substituted by antipyrin, or more safely by lactophenin or 
phenacetin, w^hich may also relieve the nervous symptoms, 
especially headache. Itching of the skin is relieved by the 
application of lanolin, cocoa-butter, or lard, which should be 
renewed after each bath. 

Mild throat symptoms may not demand treatment ; more 
severe symptoms on the part of the throat call for the appli- 
cation of cold to the neck or the inhalation of steam and the 
use of antiseptic solutions. In general the local treatment 
of the throat symptoms in scarlet fever is the same as in 
diphtheria. When the inflammation extends to the middle 
ear puncture of the drum-membrane may become neces- 
sary. 

Turpentine, hypodermatically or internally, is recommended 
for the prevention of nephritis in scarlet fever. Fauva found 
the injections to be perfectly harmless. Children may receive 
one gramme ; adults as much as three grammes. Two or three 
injections are usually sufficient. The digestive organs must be 
watched, and if necessary the turpentine may be suspended a 



56 



INFECTIONS. 



couple of days and salines given. To prevent local irritation, 
sodium bicarbonate may be added to the turpentine. 

The treatment of nephritis will be considered under acute 
nephritis. 

Cardiac weakness may call for heart-stimulants : alcohol, 
digitalis, nitroglycerin. 

SMALLPOX (Variola). 

Definition : An acute infectious disease, characterized by 
sudden onset with chills, headache, pains in the lumbar and 
sacral regions, sweating, vomiting, epigastric tenderness, a 
typical temperature, and peculiar eruption. 

History : The disease was probably recognized long before 
the time of Christ, in India, China, and Central Africa. 
Smallpox first reached America (the West Indies) in 1507, 
and the United States (Boston) in 1649. 

Etiology : Numerous micro-organisms have been described. 
Many observers believe the disease to be due to sporozoa. 
Others believe that the specific cause of smallpox has not 
been isolated because the microscope is not capable of suf- 
ficient magnification to detect the micro-organism. 

The cause is in the sHh, as is evidenced by inoculation ; 
and in the blood, as suggested by infection of the foetus and 
as proven by inoculation-experiments. The disease shows a 
preference for the cold season. 

Smallpox was formerly considered a disease of childhood. 
Since protection by vaccination has become general smallpox 
has become so rare that children are seldom exposed to the 
infection. All ages are susceptible to the disease, with the 
possible exception of early infancy. Second attacks are rare, 
as are also attacks after vaccination. 

Smallpox — symptoms : Incubation lasts eight to fourteen 
days, usually ten to twelve days. There are no symptoms 
during incubation, except possibly some malaise late in the 
period. 

The period of invasion, lasting two or three days or longer, 
usually sets in suddenly and violently, with chill, rigors, fol- 
lowed by /ever, rising often to 103° or 104° F. on the first day, 



S3IALLP0X. 



57 



and possioly 105° to 107° F. on the second or third day. The 
pulse mav reach 100-130; in children 160. Prostration is 
marked. 

There are thirst, loss of appetite, often constipation. The 
tongue is coated and the breath offensive. Some claim that 
the odor of the breath at this time is characteristic. Very 
frequently there is gastric irritation, sometimes accompanied 
hv epigastric tenderness. Among the nervous symptoms are 
headache, which is almost always present in greater or less 
degree ; delirium, especially when the temperature is high ; 
coma, convulsions, especially in children, and pain in the 
bach, especially in females. Headache, pain in the loins, and 
gasfrl'- irrifnfion usually continue from the onset of the dis- 
ease until the eruption appears. 

The urine is diminished in quantity, there is a diminution 
r)f the chlorides, and in severe cases albumin may be present. 
A large quantity of albumin in the urine, if not due to 
chronic disease of the kidney, would probably point to the 
malignant type of smallpox. 

The spleen may be enlarged in unmodified smallpox. 

Often on the second day of the invasion there is an initial 
eruption, a roseola, lasting not longer than two days, which 
has been variotisly described as presenting the appearance of 
erythema, scarlet fever, and measles. Cases in which this 
eruption is marked have been observed to run a milder course. 
Sijmetimes an initial eruption appears in one of Simon's tri- 
angles as petechice. (Simon's " triangles " are in the groin, 
hvpogastric region, inner surface of thigh, axilla, and inner 
surface of arm.) This eruption is found most frequently in 
a triangle, the apex of which is at the knees, and the base on 
a line extending transversely across the body at the level of 
the umbilicus. Petechi?e have no diagnostic import. 

The ervjjtion appears usually on the third day, first on the 
forehead and temples, near the margin of the scalp, and on 
the wrists. The eruption shows preference for the cutaneous 
and mucous surfaces exposed to the atmosphere, spreading 
rapidly to the scalp, ears, forearms, hands, and to the 
body and lower extremities in twenty-four hours. At first 
the eruption appears as little red points^ macides, which be- 



58 



INFECTIONS. 



come indurated papules in twenty-four hours. The papules 
feel like shot in the skin. At first discrete, the papules 
become confluent as they increase in number. About the 
fifth day of the disease, after the eruption has lasted some 
three days, the papules which appeared first, will contain 
serum, at first clear (vesicles), becoming cloudy and milky 
(pustules), by the fourth or fifth day. The vesicles become 
umhilicatecL By the sixth day the contents of the vesicles 
have become distinctly purulent (jmstules). The vesicles and 

Fig. 5. 



SEASE 1 2 3 4 5 G 7 8 9 10 H 12 13 14 15 16 17 IS 19 20 



ro6 



99 

NORMU 
TEMP. 

—98- 




Initial fever. Eruption. Secondary fever. 

Temperature in smallpox. 



pustules appear ^rst upon the face and extend in the order of 
appearance of the rash over the body and extremities. 

With the exanthem there appears an eruption upon the 
mucous membranes that are exposed to the external air^ espe- 
cially the mucous membrane of the mouth, nose, and phai^ynx, 
sometimes in the vagina, rectum, and urethra. 

The temperature, which often reaches 106° F., usually falls 
when the eruption appears, but may continue until the third 
or fourth day of the eruption (Welch). The temperature 
then falls, to become normal or even subnormal, usually 
within twelve to eighteen hours. At the same time there is 
a reduction in the pulse, respiration, and symptoms of gastric 
irritation. With the pustular stage the temperature again 
rises, reaching 102°, frequently 104^, rarely 106° or 107° F., 
with morning remissions. This secondary fever (Fig. 5) is a 



SMALLPOX. 



69 



part of the disease, but later shows, as a rule, the ^^strepto- 
coccus-curve " of sepsis (see Septicaemia). During this stage 
there may be disturbances of the cerebral functions, particu- 
larly delirium in various degrees. 

Desiccation begins on about the eleventh or twelfth day of 
the eruption, with improvement in all the symptoms. With 
the drying up of tlie pustules there is often considerable 
itching, and frequently it becomes necessary to restrain the 
patients, especially children, from scratching and thus pro- 
ducing unsightly scars. The process of desiccation requires 
three or four weeks. During this time the fever disappears 
by lysis. 

Smallpox — complications : The shin may show multiple ab- 
scesses, erysipelas, boils, bedsores, pigmentation from derma- 
titis, acne pastulosa, and swelling of the hands and feet. 
The eyelids show oedema, possibly with sloughing, and some- 
times contain abscesses. Upon the part of the eyes there 
may be conjunctivitis, pustules, keratitis. The chief ear 
complication is deafness, partial or complete. The following 
are the more common complications on the part of the various 
organs. The respiratory orgctns : inflammation of the nasal 
mucous membrane, epistaxis, laryngitis, tracheo-bronchitis, 
pneumonia, pleuritis. The circidatory organs: pericarditis, 
endocarditis, myocarditis, hemorrhage, venous thrombosis. 
The digestive organs : glossitis, stomatitis, h?ematemesis, diar- 
rhoea, colitis, peritonitis. The urinary organs: albuminuria, 
ha^maturia, acute nephritis, cystitis. The nervous system: 
delirium, meningitis, acute mania, paraplegia, peripheral 
neuritis, disseminated spinal scleroses, epilepsy, anterior 
poliomyelitis. The genitcd organs: phimosis, from oedema of 
the prepuce, orchitis, ovaritis. The most important complica- 
tion is secondary infection (see Septicaemia). 

Smallpox — diagnosis : The prevalence of an epidemic, the 
history of a previous attack, inocidation, or vaccination, are 
points that aid in diagnosis. The onset of the disease sud- 
denly, with chills or rigor, followed by fever, headache, pain 
in the back, epigastric tenderness, and vomiting, is suggestive. 
The appearance of the eruption on the third day, first upon 
the upper part of the face, extending rapidly over the body, 



60 



INFECTIONS. 



changing from macules and papules to vesicles, which are um- 
bUicated and later become pustules, stamps the disease. 

The differential diagnosis has to do chiefly with measles, 
scarlet fever, typhus fever, lumbago, simple fever, syphilis, 
chicken-pox, erysipelas, drug-eruptions, ptomaine-poisoning, 
herpes, glanders, acne pustulosa, pemphigus, acute rheuma- 
tism, meningitis, malignant or ulcerative endocarditis with 
erythematous or purpuric rash, and cerebro-spinal fever. 

The prognosis of smallpox depends largely on the p>rotection 
of the individual by previous attacks of the disease, inocula- 
tion, or vaccination ; the /orm of the disease, hemorrhagic, 
purpuric, confluent, discrete, abortive (varioloid) ; the sur- 
roundings of the patient regarding hygiene, and the compUca- 
tions that may arise in the individual case. 

The mortality is about 50 per cent, among the unvacci- 
nated, 26 per cent, among the badly vaccinated, and only 2.3 
per cent, among the efficiently vaccinated (Moore), Infants 
and age show a large mortality. The prognosis is not good 
among (h'unkards. 

Prophylaxis : Vaccination is most important. Suspected 
cases should be quarantined eighteen days. Smallpox pa- 
tients should be isolated until all the scabs and scales have 
fallen off. They should then be sponged with a sohition of 
bichloride of mercury, 1 : 2000, and given a full-length bath 
and change of clothing, after which they may safely come in 
contact with susceptible individuals. 

The room to which the patient with smallpox is confined 
should first be cleared of all unnecessary articles, pictures, 
curtains, etc. Precautions must be taken that contagion be 
not conveyed by the physician, attendants, letters, and dishes 
(fomites). In case of death the body is wrapped in a sheet 
soaked with bichloride of mercury, 1 : 1000, placed in a 
hermetically sealed casket, and should be buried as soon as 
possible. It would be better still to cremate the body. 

In the disinfection of the sick-chamber and furniture all 
articles of little value should be burned. Linen and other 
things of like nature may be boiled at least half an hour or 
exposed to a high degree of dry heat. Articles which cannot 
be subjected to moist or dry heat must be spread out in the 



SMALLPOX. 



61 



room, which is then thoroughly disinfected with formaldehyde 
gas, chlorine gas, sulphurous acid gas, mercuric chloride, or 
thiocamf. The apartments should then be well aired. 

Smallpox — treatment : Early vaccination, within the first 
four days, may lessen the severity of the disease. 

Beclere has reported the successful treatment of sixteen 
cases of smallpox with injections of the serum of a vaccinated 
calf. One aud a half liter of the serum was injected under 
the skin of the abdomen, in three doses. All the cases re- 
covered. 

Otherwise the treatment is symptomatic. The patient 
should ]je kept in bed, in a well-ventilated room with a tem- 
perature of 65° F. The diet should be light — milk, soups, 
gruels — and the patient shoidd be given plenty of pure water 
to drink. Pain calls for opium ; fever above 103° F. for 
baths, phenacetin, salipyrin, antipyrin. The throat syrrqjtoms 
may require inhalations of steam, antiseptic gargles or sprays. 
Ice is grateful. The nervous symptoms may be met with 
chloral or Dover^s powder. Pitting may be limited, before 
the formation of pustules, by touching the vesicles with pure 
carbolic acid. Some prefer anointing with oil or vaseline and 
covering the parts, especially the face, with lint soaked with a 
solution of bichloride of mercury, 1 : 5000 or 1 : 10,000; a 
1 per cent, solution of creolin, or a dilute solution of carbolic 
acid. The object is to prevent infection of the vesicles, and 
consequent destruction of tissue. 

Varioloid. 

Mild cases of smallpox — varioloid — appear most frequently 
in individuals who have received a certain degree of im- 
munity or protection through vaccination, inoculation, or 
previous attack of smallpox. Varioloid assumes special im- 
portance since infection from cases of varioloid may cause 
unmodified smallj^ox. 

Vaccinia ; Vaccination ; Cowpox. 

Definition : Vaccinia is the name given the disease produced 
in man by inoculation (vaccination) with cowpox. 



62 



INFECTIONS. 



History: Vaccination in prophylaxis against smallpox was 
introduced by Edward Jenner, 1798. 

Etiology : As in smallpox, many micro-organisms have been 
described in vaccinia, bat the etiologic relationship of none of 
them has been definitely established. Kent believes the spe- 
cific organisms of vaccinia to be a diplobaciUus. Inoculation 
of susceptible animals with pure cultures of this organism 
causes vesicles that may not be distinguished from those pro- 
duced by vaccine lymph, and the animals so inoculated are 
immune to the action of vaccine lymph. The vesicles pro- 
duced by inoculation contain the diplobacilli in large num- 
bers. The supposition that cowpox is a bovine smallpox, as 
well as the belief that cowpox is identical with horsepox and 
sheeppox, remains without final proof, although no one will 
deny the close relationship of these affections. Cowpox will 
protect man against smallpox, and inoculation with small- 
pox will protect cattle against cowpox. The immunity 
against smallpox, in man, begins on the fourth day after 
vaccination, and is highest by the ninth day, but does not 
remain complete for life. Revaccination, in order to secure 
the most perfect immunity, should be repeated as often as it 
will ^' take." Virus from the cow or from cases of vaccinia 
in man may be used. The chief danger from the use 
of humanized lymph lies in the possibility of syphilitic infec- 
tion, which may be avoided by the use of virus from a healthy 
individual, or more absolutely by the use of bovine virus, best 
in the form of so-called glycerinated lymph. Susceptibility to 
vaccination is universal, premising no previous attack of 
smallpox or vaccinia. Failure of the virus to ^'take" calls 
for another attempt. 

Vaccination— method : The virus should be rubbed into 
abrasions of the skin, made most conveniently by scarification 
or incision, which should cause the exudation of lymph 
through exposure of the superficial lymphatics, and little or 
no flow of blood. The point of selection, as a rule, is the 
left arm, near the insertion of the deltoid muscle, but usually 
there is no objection to vaccinating on the leg or some other 
part of the body. 



VARICELLA. 



63 



VARICELLA (Chickenpox ; Waterpox). 

] Definition : An acute infection of childhood, occurring espe- 
cially from two to six years of age, characterized by an erup- 
tion of vesicles, waterpox. Chickenpox is a common name 
for the disease, but varicella is not known to have any con- 
nection W'ith chickens. 

Etiology : The specific agent of infection, probably a micro- 
organism, has not been demonstrated. Usually one attack 
confers immunity. So far as we know, there is no relation- 
ship between variola (smallpox) and varicella (chickenpox). 
Varicella show^s a decided preference for children, especially 
under ten years, and very rarely attacks adults. 

Varicella — symptomatology : Incubation lasts eight to seven- 
j teen days. The invasion is marked by fever with possibly a 
I chill, vomiting, and pain in the back and legs, rarely con- 
vulsions. The eruption, first seen on the trunk, back, or 
chest, develops in a day. At first the eruption is papular, the 
little red papules becoming vesicles in a few hours. The 
i| vesicles may show umbilication, though this is usually not 
' the case. Within two days the vesicles become purulent, and 
a day or two later the eruption dries up, the crusts falling off, 
to leave as a rule no scar. The eruption appears in successive 
crops. 

Varicella — diagnosis : The symptoms are usually much 
milder than in smallpox. Prodromata are rare in varicella. 
The pocks rarely present a feeling as of shot under the skin, 
such as is found in smallpox ; they appear especially upon 
the trunk, rarely become confluent, do not present so great 

j infiltration around them, and are apparently more superficial. 

■ Prodromal rashes are more common in smallpox than in 
chickenpox. Above all, varicella occurs in childhood, some- 
times as an epidemic, but never appears as an epidemic 
among adults. Further, varicella shows no respect for vac- 

; cination. 

I Prognosis : Good. Complications do not often occur. 

Varicella — treatment : The patient should be confined to 
the house, if not to bed. The diet should be light. As a 
rule little or no treatment is required. Irritation of the skin 



64 



INFECTIONS. 



may call for the application of cocoa-butter or a dilute solution 
of carbolic acid. 

DIPHTHEEIA. 

Definition : An acute infectious disease^ caused by the Klebs- 
Loffler bacillus, characterized by a fibrinous exudate, false 
membrane, oc(;urring especially upon the mucous membrane 
of the throat, occasionally upon other mucous membranes and 
wounds. 

Diphtheria — history : The disease was recognized by the 
older physicians — Aretseus, Galen — but was not dissociated 
from other forms of sore throat. Early in the nineteenth 
century diphtheria was recognized by Bretonneau as a separate 
affection. The bacillus of diphtheria was discovered by Klebs, 
1883; isolated, cultivated, and its pathogenesis demonstrated 
by Lofifler, 1884. 

Etiology: The specific infectious agent in true diphtheria is 
the bacillus diplitherke, commonly known as the Klebs-Lofifler 
bacillus. Most cases of diphtheria show mixed infection with 
streptococci and staphylococci. Diphtheria is endemic in 
cities. Children from two to fifteen years of age are espe- 
cially liable to attack. 

Diphtheria — symptomatology : Incubation two to seven days. 
The period of invasion is announced by slight chilliness, fever, 
pains in the back and limbs. In mild cases the patient may 
not feel sick enough to keep abed. During the first day the 
temperature rises to 102°-103° F., possibly 104° F. Some- 
times in childhood there are convulsions. 

In pharyngeal diphtheria, membranous croup, there is some 
inflammation about the tonsils, palate, and pharynx, consti- 
tuting the catarrlial stage. The patient complains of dryness, 
burning, and constriction of the throat, and difficulty in svcdlov- 
ing. Soon the fibrinous exudate appears as 3. false nirmbranc, 
usually first upon the tonsils, extending by the third day to 
the fauces and uvula, possibly later to the posterior wall of 
the pharynx. The color of the membrane changes from a 
grayish-white to a dirty gray, possibly to a yellowish-white. 
At first the false membrane may be readily detached, but later 
the mucous membrane is so involved that the false membrane 



! 



DIPHTHERIA. 



65 



may be removed only with difficulty, leaving a bleeding sur- 
face, which soon again is covered with fresh exudate. Later 
the false membrane may be readily removed, after mixed 
I infection. Convalescence usually begins about the seventh to 
" the tenth day. Occasionally the disease lasts longer. Jessen 
reports a case lasting for five months, in which there were 
virulent diphtheria bacilli. Such cases are rare. 

The diphtheritic process may involve the nasal mucous 
membrane, nasal diphtheria; or the false membrane may 
I extend to the larynx, laryiirjeal diphtheria ; or to the bronchi, 
oesophagus, or Eustachian tube. Cases of diphtheria may 
appear primarily in the larynx or nose. 

Diphtheria — complications : One of the most important 
complications is post-diphtheritic paralysis, of toxic origin, 
affecting especially the pcdate, possibly the epiglottis or 
larynx, or the constrictors of the pharynx, interfering with 
deglutition ; sometimes involving the eye (strabismus, ptosis, 
and alterations of accommodation) ; sometimes affecting the 
face, or extremities, especicdly the legs, frequently with loss of 
the hnee-jerh. 

Albuminuria is found in all severe cases. Albumin in the 
urine in considerable quantity, with casts, would indicate 
nephritis. The heart shows both functional and organic de- 
rangement, tachycardia, bradycardia, pericarditis, endocarditis, 
valve-lesions, and heart-failure. Capillary bronchitis and 
broncho-pnetimonia are found in the more severe cases, 
j Diphtheria — diagnosis: The presence of an epidemic, and 
the history of exposure to infection and absence of previous 
attach, are valuable aids in some cases. A fcdse membrane 
may be present in some recess, as in the nose, and not be 
visible. Mild cases sometimes escape recognition until they 
spread infection and the disease appears in a more severe 
form. The demonstration of the bacillus diphtherice is of the 
greatest value in diagnosis, since it differentiates diphtheria 
from pseudo-diphtheria and reveals the character of mild 
cases of diphtheria, which might otherwise pass unrecognized 
and become foci of infection. The value of the bacterio- 
! logical examination in diphtheria is well indicated in the 
' emphatic statement by Osier, that '"AVhere a bacteriological 
5— P. M. 



66 



INFECTIONS. 



examination cannot be made, the practitioner must regard as 
suspicious all forms of throat affections in children, and carry 
out measures of isolation and disinfection." The occurrence 
of albuminuria with casts points to diphtheria. 

Examination for the bacillus diphtherise : The bacillus grows 
upon various media — milk, potato, alkaline bouillon, nutrient 
gelatin, glycerin-agar, etc. The growth is most rapid upon 
the blood-serum mixture recommended by Ldffler : blood- 
serum, three parts ; bouillon, one part ; to which are added 
peptone and grape-sugar, each 1 per cent., and sodium chlorid 
I per cent. After sterilization the mixture is solidified at a 
low temperature. 

A test-tube containing Ldffler's blood-serum mixture is 
inoculated from a swabbing of the throat, or a piece of the 
false membrane, and placed in the incubating-oven at a tem- 
perature of about 35° C. for twenty-four hours. If the case 
be one of diphtheria, large, moist, grayish-white, elevated 
colonies of the bacillus diphtheriae will be present, usually 
without sufficient development of other micro-organisms to 
interfere with the examination. 

From one of the colonies a slide is prepared and stained 
with Loffler's alkaline methylene-blue solution : saturated 
solution of methylene-blue, 30 c.c. ; solution of caustic potash, 
1 : 10,000, 100 c.c. Or a good double stain may be secured 
by using the modified Weigert's fibrin stain and picrocarmine, 
recommended by Welch and Abbott. 

The specimen should be examined under the microscope 
with an amplification of a thousand diameters or more. 

The bacillus diphtherise is non-motile, grows either in the 
presence or absence of oxygen (facultative anaerobic) ; it 
does not liquefy gelatin and does not form spores. 

The pseudo-diphtheria bacillus is often found associated 
with the true bacillus diphtheripe, w^iich it may closely re- 
semble. Sometimes the pseudo-diphtheria bacillus may be 
differentiated only by the lack of virulence. 

Diphtheria — prognosis : Usually good in private practice in 
cases that are seen early. A greater mortality occurs in hos- 
pital practice, since many cases are far advanced when they 
apply for treatment. Some epidemics give a higher mortality 



DIPHTHERIA. 



67 



than others. In general the prognosis is very much better 
since the introduction of the antitoxin treatment. Koenig 
and Moxter used antitoxin successfully in an infant five 
days old. 

Prophylaxis : For the protection of the community, a patient 
icifh diphtheria should be isolated as long as cultures reveal the 
presence of the bacillus diphtherife. Thus it may be neces- 
sary to prolong isolation far into convalescence. This applies 
to mild as well as severe cases. Infection may be conveyed 
by third parties — fomites. When the disease has terminated 
the sick-room and all articles that have come in contact with 
the patient should be sterilized. In cases exposed to infec- 
tion an injection of antitoxin may prevent the disease. Such 
immunity lasts from two to four weeks. Infants at the 
breast rarely contract diphtheria from an infected nurse. 
In such cases Schmid and Pflanz have demonstrated, in 
Eschericli's clinic, that tlie nurse's milk contains diphtheria 
antitoxin. If for any good reason the prophylactic dose of 
antitoxin cannot be given subcutaneously to nursing infants, 
it may be administered internally pure or mixed with eggs 
or milk. AYhen given internally the prophylactic action of 
antitoxin is not so reliable as after subcutaneous injection in 
infants, and is of no value in adults. The internal use of anti- 
toxin cannot be depended upon in the treatment of diphtheria. 
The use of antiseptic sprays, in cases that have been exposed 
to diphtheria, is of value. 

Diphtheria — treatment : The diet should be light, consist- 
ing chiefly of milk, eggs, carbohydrates, butter, and light 
meats. 

Antitoxin should be used as early as possible in all cases, 
after a diagnosis of diphtheria has been made. In doubtful 
cases it is better to make the injection of serum before a 
bacteriological examination is made, if such an examination 
cannot be made promptly, especially in cases not seen until 
the third or fourth day of the disease. Patients over two 
years of age may receive from 1500 to 2000 units; infants 
under two years, 1000 to 1500.^ The serum may be obtained 

^ An antitoxic unit ( Behring-Ehrlich) is ten times the amount of anti- 
toxin which, when mixed with ten times the minimum fatal dose of toxin 



68 



INFECTIONS. 



either in the liquid or solid form. The solid antitoxin is 
soluble in ten parts of water, and is of such strength that 
one gramme represents 5000 immunity units. If no im- 
provement follows the first injection of antitoxin, the dose 
should be repeated in eighteen to twenty-four hours, and 
again after a similar interval, if necessary. Antitoxin has 
complete control over the infection by the bacillus diphtherise, 
but not over the secondary infection by other micro-organisms 
(see Septicaemia). 

Local applications should be made of the subsulphate of 
iron. Some advise the use of the tersulphate or the per- 
chloride of iron, fuming hydrochloric acid, carbolic acid, 
bichloride of mercury, creosote, or creolin. The surface is 
best touched or painted with the remedy, with a cotton- 
wrapped sound, care being taken that none of the fluid drops 
into the larynx. 

Comfort is sometimes secured by the inhalation of steam. 
The nasal passages may be kept moist with yellow oxide of 
mercury ointment and vaselin, 1 : 6, introduced several times 
a day. Antiseptic sprays may be used ; but, as a rule, these 
accomplish more in the prevention than in the cure of diph- 
theria. 

The toxic symptoms are best met with alcohol. A weak 
heart may be supported with digitalis, })est in the form of 
the fresh infusion. Quicker results are secured with nitro- 
glycerin. Severe cases may demand the use of camphor, 
ether, alcohol, or musk subcutaneously. In all cases, espe- 
cially in adults, the patient should be kept abed, that undue 
strain may not be thrown upon the heart. Paralysis calls for 
the UvSe of electricity and strychnin. Severe dyspnoea, indi- 
cating obstruction of the larynx, may demand intubation or 
tracheotomy. 

Complications should receive proper attention. 

for a 250-gramme guinea-pig, and injected snbcutaneouslv, will neutralize 
the poisonous effect of the toxin and permit the test-animal to remain ap- 
parently unaffected. The guinea-pig must not vary in weight over 15 
grammes from 250 grammes, and on the seventh day after the injection must 
be alive and within 20 grammes of the original weight. 



QUINSY. 



69 



Croup. 

True croup is characterized by a peculiar crowing inspiration, 
due to the presence of a false membrane in the larynx. 

In true membranous croup the most common cause is the 
bacillus diphtheriae (see Diphtheria). In other cases the spe- 
cific etiological factor is some other micro-organism, most fre- 
quently the streptococcus, especially in cases that are secondary 
to the acute infectious diseases, measles, scarlet fever, whoop- 
ing-cough, rotheln, smallpox, typhoid fever, less frequently 
iafter simple catarrh. Exceptionally cases may depend upon 
mechanical or chemical irritation, excessive heat and dry- 
ness, ammonia, chlorine, bromine, and the fuming mineral 
acids. 

xVs a rule croup occurs in children from two to seven years 
of age, although infancy is not exempt, and exceptionally the 
disease appears later in life. 

False Croup — Laryngismus Stridulus. 

False croup is characterized by a peculiar crowing inspira- 
tion, due to a laryngeal spasm. 

There is no false membrane in the larynx, such as is found 
in true croup. Sometimes there is a light catarrh of the 
larynx. The disease is found most frequently between six 
months and five years, especially in children that are confined 
in badly ventilated apartments. The attacks depend upon 
spasm of the adductors of the cords. 

QUINSY (Epidemic Tonsilitis; Suppurative Tonsilitis; Paren- 
chymatous Tonsilitis). 

Definition : An acute infection of the fauces, pharynx, and 
tonsils, probably contagious, that tends to go on to suppura- 
tion. 

The disease prefers fall and winter, and is found most fre- 
quently in adolescence, from fifteen to thirty years. 

Symptomatology : The symptoms of quinsy are marked by 
their severity. The disease comes on with chill and fever, 
103°-105° F.; pulse 110-130. There are anorexia, some^ 



70 



INFECTIONS. 



times nausea, pain in the back and limbs, headache, and 
extreme prostration. The throat is sore and dry. There is 
diffimlty in swallowing. One or both tonsils may be affected. 
The tonsils are enlarged and oedematous, sometimes to such a 
degree as to meet in the median line, or one tonsil may be 
enlarged so as to extend beyond the median line. The swell- 
ing may be detected on the outside of the neck. Deglutition 
is painful. The tonsils are tender and soon show evidence of 
the presence of pus. Pus is recognized early by palpation. 

Extreme enlargement of the tonsil and surrounding tissue 
impairs hearing by blocking the Eustachian tube, and inter- 
feres with the use of the voice. 

Prognosis : Good. Death may be caused by the abscess 
bursting and inundating the larynx, or rarely by opening into 
the internal carotid artery. But recovery is the rule. Some 
individuals seem peculiarly liable to repeated attacks. 

Quinsy — treatment : Moist heat should be applied in the 
form of poultices, hot water, or steam. Pain may be con- 
trolled best with Dover's powder, internally. Suppuration 
calls for evacuation of the pus. 

TUBERCULOSIS. 

Definition : An infection due to the bacillus tuberculosis, 
characterized by the formation of tubercles (nodules). 

Tuberculosis — history : The disease was recognized as a 
suppuration by the older clinicians. Later, after the birth of 
anatomy in the sixteenth century, nodules were observed by 
the anatomists. Early in the present century Bayle and 
Laennec ascribed the disease to the deposit of tubercle, w^hich 
they showed to be a specific product, independent of ordinary 
inflammation. Villemin (1865) produced tuberculosis experi- 
mentally by inoculation with tuberculous sputum, and declared 
the disease to be caused by a virus. Koch (1882) isolated the 
virus as the tubercle bacillus. 

Tuberculosis — etiology : The specific etiological factor is the 
bacillus tuberculosis, which gains entrance to the body through 
the ins})ired air {tuberculosis jpulmonurti) ; or the food, especially 
the milk and meat {tuberculosis intestinalis) ; or by direct 



TUBERCULOSIS, 



71 



infection of wounds {lichen tubercle) ; and possibly through 
heredity {congenital tuberculosis). 

Cornet believed tuberculosis to be disseminated chiefly 
through the dried sputum. Fliigge has shown that the dis- 
ease is most frequently spread through the agency of minute 
droplets of fluid containing bacilli, ejected during coughing, 
sneezing, etc. 

Secondary infection by streptococci, in cases of tuberculosis, 
intensifies the virulence of the toxins to a higher degree than 
would be present in either infection alone. 

Among the factors predisposing the individual to infection, 
environment — exposure to infection — is the most important. 
Bad hygienic surroundings, especially crowding, exclusion 
from fresh air and sunlight, a sedentary life, and exposure to 
dust render the individual more liable to infection. Certain 
diseases, especially bronchitis, measles, whooping-cough, influ- 
enza, diabetes, chronic nephritis, cirrhosis of the liver, chronic 
heart-disease, arterio-sclerosis, aneurism of the aorta, and pos- 
sibly above all trauma, prepare the body for infection l)y the 
tubercle bacillus. 

Affection of the tonsil may be primary or secondary, in the 
latter case being due to infection carried by the return-flow 
of lymph (Schlesinger). Such an explanation is supported in 
some cases by finding the deposit at the base of the tonsils, 
away from the crypts. Tubercular stomatitis, more often 
tubercular ulcer of the intestine, depends especially upon the 
swallowing of tuberculous sputum or the ingestion of food 
(milk) containing the tubercle bacillus. 

Laryngeal tuberculosis is usually secondary to involvement 
of the lungs. Cases of primary tuberculosis of the larynx 
are occasionally reported. Sometimes tuberculosis presents 
the general appearance of pneumonia. 

Tuberculosis of the kidney is not infrequent. 

Lichen tubercles are caused most frequently by scratching 
with contaminated hands. 

Tuberculosis of the inguinal glands following circumcision 
has been reported in a number of cases. Ten such cases were 
inoculated by one operator, who himself later died of pul- 
monary tuberculosis (Ware). 



72 



INFECTIONS. 



Tubercular myositis has been reported in some sixteen 
cases. 

A number of investigators have observed branching 
forms of the tubercle bacillus with club-shaped extremities, 
resembling tlie ray fungus. These are believed by some to 
be degenerative forms, or a reversion to the type of organism 
from which the tubercle bacillus was originally evolved. 
Friedreich, Babes, and Levaditi found the branching forms 
with club-shaped extremities early in the course of experi- 
mental tuberculosis. Brons proposes the term " myco-bacte- 
rium of tuberculosis " for the tubercle bacillus. 

Tuberculosis — symptomatology : Most cases begin with bron- 
chitis, manifested by cough, at first dry and hacking, occurring 
especially in the morning and evening upon changing the 
posture. The expectoration, at first absent, becomes abundant; 
at first mucoid, later muco-purulent, and possibly containing 
blood. Microscopic examination of the sputum reveals the 
presence of the bacillus tuberculosis, later elastic tissue. 
Hcmioptysis usually means tuberculosis. 

Frequently the first symptom noticed is dyspepsia, often 
associated with ancemia, chlorosis, amenorrhoea, and general 
degradation of health. These are regarded as symptoms of 
toxaemia. 

Only too often the onset is so insidious as not to ( ause the 
patient to seek medical advice until the disease is far ad- 
vanced. 

One of the early symptoms is shoi^tness of breath upon ex- 
ertion. Later there is dyspnoea, due to cardiac weakness, 
sometimes associated with cyanosis. Pain in the chest is a 
common symptom, due to pleurisy, sometimes to neuralgia of 
the intercostal nerves, caused by toxaemia. The temperature 
at first may be normal or subnormal in the "morning ; but 
shows early a rise some time during the day, usually in the 
afternoon. With the fever there may be night-sioeats. Later 
the temperature becomes higher, 103° F., possibly 104° F., 
with daily remissions of two or three degrees. After sec- 
ondary invasion by the pyogenic micro-organisms takes place, 
constituting the period of " hectic,^' the temperature varies 
from 103° to 105° F. in the evening, but is normal or sub- 



TUBERCULOSIS. 



73 



normal in the morning, constituting the streptococcus- 
curve^^ (see Fig. 1). The night-sweats may be exhausting. 
The pulse, at first corresponding to the temperature, with 
increased weakness becomes rapid, compressible, and readily 
influenced by exercise. 

Frequently one of the earliest symptoms is loss of weight, 
and in the later stages emaciation is so marked as to have 
been one of the first recognized signs of the disease. Hence 
the terms, phthisis, consumption (w^asting). 

Laryngeal tuberculosis will receive separate consideration. 

Tuberculosis — physical signs : Physical signs at first are en- 
tirely absent. Inspection may reveal the characteristic long, 
narrow chest, and the winged scapulae, which have been aptly 
compared to folding doors or the wings of the eagle. The 
clavicles become prominent. The chest may show deformity. 

The habitus phthisicus, marked by a long, flat chest, with 
emaciation and weakness, formerly believed to predispose to 
tuberculosis, is now recognized as evidence of the existence 
of the disease. 

Palpation shows lessened mobility, with defective expansion 
on one or both sides. With consolidation, vocal fremitus is 
increased. In cases of pleural exudate the vocal fremitus 
is diminished or absent. Percussion may reveal defective 
resonance, especially in the region of the clavicle. In ad- 
vanced cases percussion will show dulness from consolida- 
tion, the so-called fibroid change ; or a cracked-pot sound may 
be caused by the presence of cavities. Auscultation, as a rule, 
shows prolonged expiration early in the course of the disease. 
Later all sorts of rales may be heard. 

Tuberculosis — diagnosis : In cases far advanced the physical 
signs leave little doubt as to the character of the disease. 
Advanced cases often show elastic tissite in the sputum ; but 
this may appear in other diseases, especially in abscess or 
gangrene of the lung, and sometimes is not present even late 
in tuberculosis. As a rule, an earlier diagnosis may be made 
by the discovery of the tubercle bacillus (Fig. 6). 

Examination for the bacillus tuberculosis : Some sputum is 
collected in a clean vessel. From the specimen a suspicious 
yellowish or whitish particle is selected, or a film is spread on a 



74 



INFECTIONS. 



slide or cover-glass with a cameFs-hair brush. If the sputum 
is very tenacious, it may be better to add some caustic soda 
or potash and precipitate the bacilli with the centrifuge. The 
film is allowed to dry, and is then fixed by passing through a 
flame, specimen side up, three times. The specimen is now 
ready for the stain. Probably the most satisfactory stain is 
the Ziehl carbol-fuchsln solution: fuchsin, 1 c.c; absolute alco- 
hol, 10 c.c; carbolic acid crystals, 5 c.c; distilled water, 
100 c.c The specimen is covered with, or floated upon, this 
solution, under gentle heat, just sufficient to cause steam 



Fig. 6. 



\ 



1^ t 



Tubercle-bacilli. Sputum of a man suffering from tuberculosis of the lung, spread 
in a thin layer on a cover-glass and stained with fuchsin and methylene-blue 
(Ziegler). 



to rise, usually thy^ee to five minutes. Decolorize everything 
but the tubercle bacillus by the use, for about thirty seconds, 
of acid alcohol: hydrochloric acid, 1 c.c; 70 per cent, alcohol, 
100 c.c Wash with absolute alcohol and then with water. 
Counterstain with a saturated aqueous solution of methylene- 
blue. Wash off the surplus stain with water, dry and mount, 
best in glycerin or balsam. The tubercle bacilli appear red 
upon a blue background. 

Tuberculin test: Still earlier in the course of tuberculosis, 
before bacilli are thrown ofiP through the sputum or when 
they are so few in number as to be difficult to find, the diag- 
nosis may be made by a test-injection of one milligramme 
of Koch's old tuberculin, which causes a rise of fever in 
tuberculosis, but no temperature-reaction in non-tubercular 



TUBERCULOSIS. 



75 



cases. This method is of especial value, since it discloses 
tuberculosis not only of the lungs, but anywhere in the body. 
The cases in which other diseases (actinomycosis, leprosy) 
have been reported to give the reaction were probably cases 
in which a coincident tuberculosis in some part of the body 
w^as overlooked. 

Pronounced agglutination and bactericidal power have been 
found in the serous fluid from local tuberculous lesions. In 
non-tubercular cases there is no such reaction. 

Tuberculosis — prognosis : The spontaneous cure of tuber- 
culosis is not uncommon. In fully one- third of autopsies 
(Mossini, 39 per cent., quoted by Osier) upon individuals who 
have died of some disease other than tuberculosis there is evi- 
dence of pre-existing tuberculosis. 

In a general way it may be said that two-thirds of man- 
kind have tuberculosis, and that two-sevenths succumb to 
pulmonary tuberculosis, and fully one-third to tuberculosis 
in some form, including affections of the intestine, bones, 
glands, etc. 

Much depends upon the environment, especially as regards 
autoinfection of patients from their own sputum. The symp- 
toms of sepsis are ominous. When treatment is begun before 
the development of septic symptoms the outlook is not so 
bad. 

Froebelius, in the post-mortem examination of 18,569 in- 
fants, found the cause of death to be tuberculosis in 416, 
about 0.4 per cent. 

Tuberculosis — prophylaxis : The community as well as the 
individual should be protected by destruction of the sputum, 
best by fire. Promiscuous expectoration should be absolutely 
prohibited. Cuspidors must contain water or some antiseptic 
solution. Crowding, especially in a tuberculous atmosphere, 
favors contagion, as do also the inhalation of dust and the 
exclusion of fresh air and sunshine. 

It would be better for society if all tuberculous patients 
could be isolated. 

After a case of tuberculosis the sick-room and everything 
that has come in contact with the patient should be disinfected. 

For the protection especially of infants, dairies should be 



76 



INFECTIONS. 



inspected systematically with reference to the presence in the 
milk of tubercle bacilli. Tuberculous animals should be 
killed. 

Tuberculosis is found less frequently by far among the 
cattle of Colorado than among the cattle raised in less elevated 
portions of this country. Gardiner concludes that in a drink 
of milk taken in a city below 2000 feet above the sea-level the 
risk of tuberculosis intestinalis is about 30 per cent, greater 
than in an elevated region such as Colorado. 

Tuberculosis — treatment : In the way of specific medication, 
the new tuberculin of Koch (T. R.) is of the greatest value, 
especially in cases of pure tuberculosis, but it has no control over 
the " sejjsis of phthisis.^ The remedy is given hypodermati- 
cally, preferably in the back, beginning with 0.001-0.002 mg. 
and gradually increasing up to 20.0 mg. The tuberculin is 
usually dissolved in 20 per cent, glyceriuj to which 0.6 per 
cent, sodium chloride has been added. A solution containing 
mg. of tuberculin to 1.0 c.c. is used at first, the injections 
being given every day, sometimes every second or third day, 
beginning with 1.0 c.c. of the solution, or, in very bad cases, 
0.5 c.c, and increasing 1.0 c.c. each injection until the dose 
reaches 10.0 c.c. The solution is then increased in strength 
and the injections again gradually increased from 1.0 c.c. to 
10.0 c.c. Again the solution is increased in strength, and so 
on until pure tuberculin is used, gradually increasing the in- 
tervals between injections as the injections increase in size, so 
that when the large doses are reached, the patient receives 

^Besides Koch's new tuberculin, commonly known as T. R., prepared 
from whole tubercle bacilli pulverized in a mortar, the following have been 
recommended to address the specific cause of tuberculosis : Tuberculin 
(Koch), a glycerin extract of the tubercle bacillus, commonly known as 
Koch's old tuberculin, which is used chiefly for diagnostic purposes; tuber- 
culocidin (Klebs), a modification of tuberculin; antiphthisin ( Klebs), prac- 
tically same as above; tuberculinum purificatum (v. Ruck), practically 
ditto; purified tuberculin (Whitman), practically ditto, made from the 
culture-fluid in which the tubercle bacilli have grown; oxytul erculin 
(Hirschfelder), a 5 per cent, solution of tuberculin saturated with peroxide 
of hydrogen under protracted heat ; V. Ruck's aqueous extract of dead 
tubercle bacilli. 

Serums : Maragliano's serum ; antitubercle serum (Paul Paquin) ; Cran- 
dall's immunized serum; Mulford's ass' serum, antituberculin serum; anti- 
phthisic serum (Fisch). 



TUBERCULOSIS. 



77 



one injection in one or two weeks. The injections should 
cause no fever, and are of most value when there is no, or 
but little, fever. 

ji The solutions of tuberculin must be kept where it is cool 
t but not damp ; and should they become cloudy they must not 
be used. This caution is important. For the laryngeal ulcers 
perhaps nothing is better than the local application of lactic 
acid. 

Fever and night-sweats, evidences of the sepsis of phthisis, 
Ij disappear when the individual remains in the open air day 
and night. Night-sweats may be controlled with atropine, gr. 
yJ-q— gig-. Aromatic sulphuric acid combined with gallic acid 
is also highly recommended. Diarrhoea may be controlled 
for a time with bismuth, best in combination with Dover's 
powder, or by enemata of starch and laudanum, or acetate, of 
lead and opium in pill, or by tannalbin or tannigen. Hmmop- 
tysis, when the hemorrhage is from the lungs, may be relieved 
by morphine and atropine, at first hypodermatically, later per 
OS, with rest in bed and the application of an ice-bag over the 
j heart. Among other remedies recommended for haemoptysis 
' are : ergotin, sclerotinic acid, aconite, aromatic sulphuric acid, 
tannic acid, lead, and gallic acid. 

For the relief of the septic symptoms, aside from life in the 
open air, probably nothing equals the aromatic oils containing 
sulphur. Of these the oil of garlic is especially beneficial, 
but its use is seldom practicable because of the odor. 
! Intrapulmonary injection with iodoform in oil has been 
suggested by the success attending the use of iodoform in 
surgical tuberculosis, as of the joints, and deserves a further 
trial. 

Alexander recommends campor subcutaneously. The rem- 
edy is antihydratic, antipyretic, and a cardiac stimulant, and 
lessens the suppuration and cough. 

1 Sanitaria are of value in the management of tuberculosis 
chiefly in so far as such institutions may secure the proper 
climatic, hygienic, and dietetic treatment of cases. 

I Frequently good results may be obtained by the use of 

I cinnaraic acid, or, better, the cinnamate of sodium, given by 

' intravenous injection. 



78 



INFECTIONS. 



Nebulization of the various essential oils has been recom- 
mended. These remedies may exert a beneficial effect, espe- 
cially upon the sepsis of phthisis, but are not a satisfactory 
substitute for the open-air treatment. 

Recovery from tubercula?' meningitis has followed lumbar 
puncture. 

In tubercular Icty^yngitis pain may be relieved by insuffla- 
tions of orthoform, gr. v, or by painting the surface with a 10 
per cent, solution of the hydrochlorate of orthoform (Nau- 
mayer). 

Tuhei'Gular pleuritis which does not show a tendency to 
undergo resolution promptly may demand thoracentesis and 
possibly the resection of one or more ribs. 

LEPROSY (Lepra; Elephantiasis Graecorum; Aussatz (German)). 

Definition : A chronic infectious disease, due to the bacillus 
leprae, characterized by changes in the skin (tubercidar leprosy), 
and in the nerves (ancesthetic leprosy), and also in the bones 
and other tissues. 

History : Probably reference was made to leprosy by Moses. 
The disease was described in detail by Celsus, 25 A. D. His- 
tory shows the gradual extension of leprosy westward, from 
Egypt to the Orient, India, Persia ; to Greece, Italy, later to 
Spain, France, and Germany ; to England and Scotland in 
the tenth century. It was spread all over Enrope by the 
Crusades in the eleventh and twelfth centuries, to be brought 
under control by segregation in the fifteenth to the seventeenth 
century. 

Leprosy is endemic in northern and eastern Africa, Mada- 
gascar, Arabia, Persia, India, China and Japan, Norway and 
Sweden, Italy, Greece, France, Spain, and the isla'nds of the 
Indian and Pacific Oceans. TJie disease is found in Central 
and South America, Mexico, the West Indies, Hawaii, Aus- 
tralia, and New Zealand, and also in New Brunswick, Canada. 
In the United States most cases occur in Louisiana and Cali- 
fornia, occasionally in Florida, New York, Ohio, Pennsyl- 
vania, Minnesota, Missouri, North and South Carolina, and 
in Texas. 



LEPROSY. 



79 



Etiology: The bacillus kprcE is generally accepted as the 
specific cause of leprosy^ although this has not been demon- 
strated by the production of the disease in man through inocu- 
lation with a pure culture of the bacillus. 

The bacillus leprae bears a marked resemblance to the 
tubercle bacilltis, from which it may be differentiated by bac- 
teriological methods, especially by its affinity for acid stains^ 
such as eosin and acid ftichsin. 

Leprosy may be communicated through inoculation. The 
disease is jn'obably not contagious except upon close contact. 
As a rule, ca-es do not present open ulcers ; and when there 
are ulctr- rlie superficial bacilli are usually dead. Hereditary 
tran^missi'Mi has not been proven. 

Kaposi has reported a case in which a leproma developed 
where an individual had been bitten upon the finger by a 
mosquito. Sommer has observed that leprosy is more frecpient 
where mosquitoes occur in large numbers. 

Leprosy — symptomatology : The period of incubation has 
been stated to be from a few weeks to as long as twenty or 
even forty years, probably most frequently from three to five 
years. 

Among the premonitory symptoms are irregular fever, mal- 
aise, anorexia, dy-pepsia, epistaxis, dryness of the nasal pas- 
sages and rt-|)iratory tract, vertigo, headaches, neuralgias, 
rheumatic pain-, articular pains, exaggerated functions of the 
kidneys and sweat-gland-, anxiety, prtiritus, and hypersesthesia 
of the -kin. 

Erythematous eruptions may appear in various parts of the 
body, constituting the macular stage. Bullae may appear over 
the aniculations of the fingers and toes, knees, elbows, wrists, 
and ankles. The appearance of nodules, especially upon the 
forehead, eyelids, nose, lips, chin, cheeks, and ears, constitutes 
the so-called tubercular leprosy. The nerve-trunks are thick- 
ened. 

, Ancesthetic leprosy may start as an ulcer, appearing usually 
I as the result of numerous bullte re-forming in the same 

I'xaliry. Patches of anaesthesia, sometimes hypersesthesia, 

may a])]-)ear in various parts of the body. 

Anfesthesia of the little finger is said to be one of the most 



80 



INFECTIONS. 



constant symptoms, often appoiiring before other lesions in 
the liand. The tendon reflexes are exaggerated. J^ator there 
are marked trophic changes, atropines, paralyses, etc. 

Usnally the disease appears tirst as the tubercular form of 
leprosy, sometimes as the anaesthetic form, and later takes on 
the symptoms of the other variety. 

Leprosy — diagnosis : Usually the history and symptoms are 
Sufficient to make the diagnosis. In case of doubt, the body, 
including the suspicious macuhTe, may be rubbed with fuchsin 
methyl-violet in powder, then covered with absorbent cotton, 
and perspiration caused by the injection of pilocarpin : the 
sound skin will l)e colored, while the leprous spots, which do 
not perspire, will not be stained (Baelz). Or the tissue may 
be searched for the bacillus lepne. 

Leprosy should be differentiated from morpha^a, syphilis, 
iodism, sarcoma, molluscum fibrosum, lichen planus, dysidro- 
sis, and Morvan's disease (if this be not, indeed, a variety 
of leprosy, or leprosy a causative factor of Morvan's disease). 

Leprosy — prognosis : The average duration of life, about 
eight years, is greatly exceeded in souie cases. 

Prophylaxis : Segregation will prevent spread of the disease. 
In all cases absolute cleanliness should be observed, including 
destruction of all excreta and the protection of open sores. 
The patient should use individual utensils and occupy a sepa- 
rate sleepi ng-apartment. 

Leprosy — treatment : Probabl}^ the remedy of mOvSt value is 
gynocardia (chaulmoogra) oil, Gynocardia odorata, given 
internally, beginning with gtt. ij in capsule or milk and in- 
creased to tolerance, usually about two drachm doses, half an 
ounce a day. 

Among many other remedies which have been highly rec- 
ommended may be mentioned gurgun oil (dipterocarpus tur- 
binatus), Hlv-x internally with lime-water; ic^hthyol, inter- 
nally and externally ; pyrogallic acid and resorcin, externally ; 
salol and salicylate of sodium, internally ; morphine and oil, 
hypodermatically ; potassium chlorate, internally in large 
doses (gr. 180-380 per day. Dyer) ; oxygenated muriate of 
potassium ; the bites of venomous snakes ; the serum obtained 
from leprous lesions; the use of tonics, stimulants, and pallia- 



SYPHILIS. 



81 



tive measures. Various baths are recommeuded In many 
cases an appeal must be made to surgery. 

SYPHILIS (Pox ; Lues Venerea). 

Definition : A chronic infectious disease, transmitted through 
heredity [congenital syphilis) or through inoculation [acquired 
syphilis). 

In acquired syphilis, a sore at the site of inoculation, after 
an incubation of two or four weeks, constitutes the primary 
lesion. Two or three months later the secondary lesions 
develop : affections of the skin and mucous membranes, sore 
throat, cutaneous eruptions, and condylomata. The third 
stage of the disease develops after a period of three or 
more years, with falling of the hair, gummatous growths 
in the viscera, muscles, bones, or skin — so-called tertiary 
lesions. 

Etiology : From a bacteriological standpoint the etiology of 
syphilis is not clear. Micro-organisms have been described 
by Lustgarten (1884); Eve and Lingard (1886); Disse and 
Taguchi (1886) ; Golasz (1894); and Yan Niessen (1898). 
One difficulty encountered by bacteriologists is the fact that 
animals are not subject to syphilis. 

It is known that syphilis may be conveyed by inocidation, 
and that the abrasion need be but slight. Thus infection is 
transmitted through sexual intercourse, kissing, and through 
the use of common utensils and vessels for eating and 
drinking. Physicians have frequently been inoculated in the 
examination or treatment of cases of syphilis, especially in 
surgical and obstetrical practice. Occasionally syphilitic in- 
fection occurs during circumcision. 

Hereditary syphilis may be transmitted from either parent, 
in whom the disease may be either manifest or latent at the 
time. Syphilitic infection of a mother at the seventh month 
of gestation usually does not affect the foetus, although the 
foetus has been reported to be affected as late as the eighth 
month of gestation. The mother need not necessarily be 
affected by syphilis transmitted to the offspring from the 
father, and may afterward nurse the child without becoming 
6— p. M. 



82 



INFECTIONS. 



infected, probably through having received a protective inocu- j 
lation without the development of the disease. The child 
may convey syphilis to a wet-nurse who has received no such 
protection. Hereditary syphilis is usually found in the first 
three months of life, often at the time of birth. Not infre- 
quently abortion or miscarriage is due to inherited syphilis in 
the foetus. 

A distinction should be made between syphilis acquired 
with conception and syphilis acquired during intra-uterine , 
life ; but for practical purposes hereditary syphilis is usually 
considered synonymous with congenital syphilis. 

Symptomatology : After an incubation of two to four weeks 
the primary sore, ulcus durum, appears at the point of inocula- 
tion, first as a small red papule, which later breaks down in 
the centre to form an ulcer. The ulcer has an indurated base; 
hence the term hard chancre. The primary sore varies in 
size, and when small may be overlooked, particularly when 
located in the urethra. In the female the sore is usually on 
the inner side of the labia or on the vaginal portion of the 
cervix. The lymphatics in the neighborhood of the primary 
sore are enlarged, and suppuration may occur both in the 
primary sore and in the adjacent lymphatics. The early 
symptoms of hereditary syphilis are peevishness and irrita- 
bility at night, harsh and difficult breathing, snuffles, sore 
mouth, and impaired digestion, with emaciation and the '^old 
man appearance. There may be characteristic eruptions. r 

Second stage : Usually in from six to twelve weeks consti- If 
tutional symptoms are observed ; fever, ancemia, cutaneous 
and mucous lesions (macules, papules, and pustules ; squamous f 
syphilides, condylomata, falling of the hair, mucous patches, , 
stomatitis, and sore throat), and ciffections of the eye (iritis, t 
keratitis, and affections of the optic nerve), sometimes affec- ] 
tions of the ear, and occasionally epididymitis and parotitis. ; 

Third stage: After a period of several years the so-called 
tertiary symptoms appear. These are chiefly ^km-eruptions, \ 
gummatous grotvths in the viscera, and amyloid degeneration. 

Other characteristic symptoms of syphilis are the pains in 
the bones, especially at night ; the sunken bridge of the nose, ; j 
and the notched teeth. The bone-lesions in congenital syphilis ) , 



SYPHILIS. 



83 



are usually found after the sixth year. Sometimes syphilis 
involves the kidneys and lungs. 

Congenital syphilis may or may not be present at birth. 
Among the most characteristic symptoms are those due to a 
syphilitic rhinitis, which has given the name smijfles^^ to the 
disease. The symptoms of congenital syphilis, when not 
present at birth, as a rule become manifest within the first three 
months, and resemble those of acquired syphilis, except that 
the primary sore is not present. 

P. Si lex recognizes in congenital syphilis three character- 
istic signs: 1. A choroidea areolaris, in which there are 
scattered over the fundus of the eye, especially in the neigh- 
borhood of the macula, black points and patches, with here 
and there white spots of various sizes and larger areas with 
a black border. These represent atrophic colonies in the 
choroidea, and pigment-patches from the pigment of the 
stroma and epithelium Vision is impaired from involvement 
of the retina. 2. A central crescent-shaped excavation in the 
permanent upper incisors denuded of enamel. 3. Pseudo- 
scars radiating from the corners of the mouth to the cheek 
and chin. 

Cases of syphilis hereditaria tarda, in wliich the disease was 
acquired by heredity, but did not become manifest until a 
long time after birth, have been reported. The existence of 
such cases is doubted by many, who are inclined to believe 
that they are really acquired, and that the initial lesion has 
been overlooked. 

Syphilis affects the bloodvessels (endarteritis obliterans) and 
precipitates the changes of age (arterio-sclerosis). In the 
liver syphilis may cause cirrhosis, or the formation of gum- 
mata. The testicle may be involved in a sarcocele, marked 
by the absence of pain and fluid, and usually of slow 
growth. 

Diagnosis : A negative history is of little value in diagnosis. 
Frequently the ])rimary sore is not recognized. A history of 
an eruption, faltiag of the hair, iritis, sore throat, or repeated 
miscarriages or abortions, may be obtained, and is suggestive. 
Superficial bone-surfaces (tibia) may be examined for nodes. 
Copper-colored cicatrices may be found on the legs, or a scar 



84 



INFECTIONS. 



may indicate the site of the primary sore. The testicles may 
show atrophy or hardening. Usually enlargement of the 
lymphatic r/lands may be detected. Depressed nasal bones 
or the presence of ozcena may throw light upon a case. The 
notched teeth of syphilis — the so-called Hutchinson teeth — 
are due to a disturbance of nutrition, and are not pathogno- 
monic of syphilis, although frequently present in that disease. 

Congenital syphilis shows early snuffles and a skin-rash. 
About three-fourths of cases develop symptoms of syphilis 
within the first three months of life ; but a negative diagnosis 
should not be made within less than a year after birth. 

Doubtful cases may be cleared up by the therapeutic test 
with mercury and iodides. 

Prognosis : Although syphilis is a chronic disease, the prog- 
nosis under proper treatment is usually good. 

In hereditary syphilis the chances are more favorable for 
the child in cases of infection from the father in which the 
mother remains healthy. 

In 1700 pregnancies destruction of the ovum or foetus oc- 
curred in about one-third of the cases; 1121 children were 
born alive, and of these children 966 died during the first 
year of life (Hyde). 

Prophylaxis : Segregation would be eflPective, but is imprac- 
ticable. Promiscuous sexual intercourse, the habit of kiss- 
ing, and the use of common drinking-vessels are largely 
responsible for the propagation of syphilis, and should be 
prohibited. 

Sexual relations should not be permitted until after at least 
two years' active treatment of syphilis. 

Fournier has wisely remarked that nothing is so dangerous 
to the surroundings as a syphilitic infant (Bulkley). 

In cases of hereditary syphilis the father may be treated ; 
the mother must be (Sturgis). 

Syphilis — treatment: Some advise excision of the primary 
sore, since it is a focus of infection. When this is done, 
medicinal treatment is begun at once ; but usually active 
treatment is deferred until the second stage. 

In the treatment of the second stage, mercury, in the form 
of the ointment, may be given by inunction, a drachm a day 



SYPHILIS. 



85 



for six days, with a bath on the seventh day, the inunction 
being begun again on the eighth day and continued as before. 
The patient should be directed to make the applications suc- 
cessively to the forearms, arms, chest, abdomen, thighs, and 
legs, upon different nights. 

Or mercury may be given internally, in the form of calomel, 
or the hydrargyrum cum creta (chalk-mixture, gray powder), 
with Dover's powder, one grain of each in pills, four to six 
times a day ; or the biniodide of mercury, gr. or the prot- 
iodide of mercury, gr. three times a day. 

Mercury may also be given by injection into the muscles, 
bichloride, gr. | in gtt. xx of water, or calomel, gr. j-ij in Tllxx 
of glycerin, injected once a week. Mercury may also be given 
hj fumigation. Inhalation of mercury often gives excellent 
results ; indeed, it is believed that when inunctions of mer- 
cury are used the mercury must enter the system through the 
organs of respiration, since it is well known that very little 
of the mercury is absorbed through the skin. 

During mercurial treatment, salivation should be guarded 
against by keeping the teeth and mouth clean, avoiding acids, 
green vegetables, and fruit. Should symptoms of salivation 
supervene, manifested by tenderness of the gums, the use of 
mercury may be suspended, or potassium chlorate may be 
given, a teaspoonful of the saturated solution every two 
hours. 

Congenital syphilis may be treated with mercury by in- 
unction or internally, in the form of the hydrargyrum cum 
creta. Later manifestations may call for the " mixed treat- 
ment,'' Gilbert's syrup (biniodide of mercury, gr. j ; iodide 
of potassium, half an ounce ; water, two ounces), gtt. v— x 
three times a day, gradually increased to tolerance. 

Syphilis in infants may be treated indirectly through the 
administration of mercury and the iodides to the nurse. 

Children with hereditary syphilis almost invariably die if 
taken from the breast. This has generally been attributed to 
decreased nutrition, but possibly may be due to some sub- 
stance of therapeutic value in the mother's milk. 

In the treatment of the third stage the iodides, especially 
the iodide of potassium, takes the place of the mercury used 



86 



INFECTIONS. 



in the second stage. The patient may begin with gr. x, 
gradually increased to gr. xxx or more, largely diluted, in milk 
or water three times a day. 

In all cases it is advised to continue treatment at least two 
years. Some believe that this length of time may be made 
shorter by the use of injections of mercury. 

CHANCROID (Soft Chancre ; Ulcus MoUe). 

A venereal sore, that appears within a day after infection 
as a red spot upon the glans penis. At first a papule, it be- 
comes a day or two later a vesicle. Rupture of the vesicle 
forms an ulcer, characterized by a profusely suppurating base. 
The ulcer causes infection of contiguous structures, and often 
spreads through the lymphatics to cause suppuration of the 
lymphatic glands — bubo. Inoculation-experiments are suc- 
cessful in apes and man. 

Diagnosis : The rapid onset, the absence of induration of the 
base of the ulcer, and the fact that there is no general infec- 
tion, differentiate soft chancre (chancroid) from the hard 
chancre (true syphilis), and make recognition of the disease 
easy. 

Treatment : When seen early the ulcer should be destroyed 
with the cautery or strong caustics, caustic potash or zinc 
chloride, or with fuming nitric acid. Later, mild treatment is 
best. The ulcer may be cleaned and covered with iodoform, 
europhen, dermatol, calomel, or bismuth. 

GONORRHOEA (Blennorrhoea ; Urethritis Specifica ; Clap ; 
Tripper (German)). 

Definition : Infection of the urethra by the gonococcus. 

Etiology : The specific cause is the gonococcus, micrococcus 
gonorrhoeae, a diplococcus discovered by Neisser (1879). In- 
fection occurs usually through impure intercourse, to cause 
greater or less involvement of the genito-urinary system. 
Thus there may be produced a specific urethritis, affecting 
sometimes the posterior urethra ; prostatitis, adenitis (bubo), 
orchitis ; salpingitis, oophoritis, metritis, peritonitis ; cystitis, 



GOXORnnCEA. 



87 



ureteritis, pyelitis, and nephritis. Careless manipulations may 
permit inoculation of the anus, condylomata ; or of the eye, 
conjunctivitis. During parturition from an infected mother 
a child may be inoculated, to cause most frequently affection 
of the eye, conjunctivitis, blennorrhcea neonatorum; less fre- 
quently, vaginitis or stomatitis. 

The gonococcus has been found in the blood and upon the 
valves in cases of gonorrhoeal endocarditis. Pericarditis, 
pleurisy, and myocarditis are rare. Gonorrhoeal arthritis is 
more frequent. Sometimes pure cultures of the gonococcus 
may be obtained from infected joints. The knee-joint is the 
more frecpiently involved. Often the gonococcus opens the 
way for secondary invasion by other micro-organisms (see 
Septicaemia). 

Gonorrhoea — symptomatology : Incubation, two or three days. 
The symptoms come on with dysuria, painful erections 
[chordee), a niuco-pvruhj nt discharge, becoming later a more 
or less continiiotis discharge of pus — pyuria. In bad cases 
there may be a bloody discharge, due to the destruction of 
tissue. As a rule there is fever, probably caused by the 
absorption of toxins. Infection of the lymphcdics may cause 
enlargement of the glands in the groin. Sometimes there is 
affection of the testicle, especially of the epididymis, with 
effusion into the tunica vaginalis. Condylomata may appear 
upon the glans penis or perineum. Infection of the glands 
of Cowper is announced by a sense of weight and pain, and 
the appearance of a tumor, in the median line of the peri- 
neum. Suppuration with discharge into the urethra may lead 
to the formation of fistula?. 

Among the nervous phenomena are insomnia, headache, 
priapism, and emotional disturbances; the individual becomes 
irritable, sometimes dejected. 

The chief complications and seguelse are prostatitis, adenitis, 
peri-urethral and prostatic abscess, orchitis ; vulvitis, vagin- 
itis (leucorrhoea), metritis, salpingitis, oophoritis, sometimes 
peritonitis ; cystitis, ureteritis, pyelitis, nephritis ; arthritis, 
endocarditis, septicaemia, conjunctivitis, iritis ; pericarditis, 
pleurisy ; synovitis, and stricture. 

Diagnosis : The symptoms, especially dysuria and pyuria, 



88 



INFECTIONS. 



may arouse suspicion ; but a positive diagnosis may be made 
only upon disclosure of the gonococcus (Fig. 7). 

Examination for the gonococcus: The gonococcus is a ^'bis- 
cuit-shaped" or kidney-shaped diplococcus, arranged with its 
concavities in apposition, separated by a narrow zone. The 
organism is found ivithin pus-cells and upon epithelial cells, 
and is decolorized by Gram's method. Cultivation is difficult, 



Fig. 7. 




Gonococci in the secretion from the urethra in recent gonorrhoea. Cover-glass 
preparation stained with methylene-blue. a, mucus with separate cocci and 
diplococci; b, pus-cells with diplococci ; c, pus-cells without diplococci (Ziegler). 

but may be accomplished upon human blood-serum, or upon 
the ordinary nutrient agar to which urine has been added. 

The gonococcus shows an affinity for the basic aniline dyes, 
especially methyl-violet, gentian-violet, and fuchsin. Prob- 
ably methylene-blue is the best stain when searching for the 
organism in pus. Beautiful double staining may be done 
with methylene-blue and eosin, or with Ziehl's solution of 
fuchsin and methylene-green. 

Prognosis: Good, under proper and persistent treatment. 
The occurrence of complications makes the outlook less 
favorable. 

Gonorrhoea — treatment : The bowels should be kept open. 
A light diet is best. Fluids, but not alcohol, should be taken 
in abundance. Rest in the recumbent posture is advisable. 
The testicles should be supported in a light bandage. Pria- 
pism calls for sponging of the organ with cold water and the 
internal use of the bromides, camphor, lupulin. Dysuria 
may be relieved by salol, the salicylates, phenacetin, or in 
severe cases by suppositories of opium or belladonna. 

After subsidence of the acute symptoms oil of copaiba 



GLANDERS. 



89 



or sandalwood may be given internally. Later the urethra 
may be treated locally with mild solutions of the acetate of 
lead or zinc, nitrate of silver, protargol, chloride of zinc, or 
aluranol. 

Posterior urethritis calls for the deep prostatic injection of 
nitrate of silver with an Ultzman catheter ; or iodoform 
may be injected, a 10 per cent, solution in pure glycerin. 
The odor may be disguised with vanillin or coumarin, 1:10. 
The remedy is injected, a syringeful at a time, immediately 
after the patient has voided the urine. Complications may 
need special treatment. Cystitis is best met by washing out 
the bladder with mild solutions of boric acid, permanganate 
of potassium, nitrate of silver, or protargol. 

Obstinate cases may sometimes be cleared up by the use of 
the endoscope, whereby a localized inflammation may be dis- 
covered and treated directly by local applications. 

Buboes may be treated by the injection in two places of a 
1 per cent, solution of the benzoate of mercury. This treat- 
ment will sometimes prove successful when incision has failed, 
and has been reported to succeed even after suppuration has 
begun. 

GLANDERS (Farcy ; Rotz (German) ; Morve (French)). 

Definition : An infectious disease, acute or chronic, com- 
municated to man from the domesticated animals, especially 
the horse, and characterized by nodules, particularly in the 
nose and beneath the skin. The disease does not aifect cattle 
nor swine. 

Etiology : Glanders is caused by the bacillus mallei, dis- 
covered by Lofiler and Schiitz (1882). The disease occurs in 
man chiefly through inoculation from diseased animals; occa- 
sionally from man. The infection is disseminated through 
the lymphatics. 

Glanders — symptomatology: Incubation, usually three or 
four days. The point of inoculation shows swelling and red- 
ness with inflammation of the lymphatics. Nodules form in the 
nasal mucous membrane and break down to form ulcers, from 
which there is a muco-purulent discharge. Papules, which 



90 



INFECTIONS. 



soon become pustules, appear on the face and over joints. 
The patient experiences chilly sensations^ fever, headache, and 
prostration. 

Chronic glanders present nasal ulcers, and often also laryn- 
geal symptoms. The disease may be mistaken for chronic 
coryza. 

Farcy, in animals, presents a phlegmonous inflammation of 
the skin at the point of inoculation. With inflammation of 
the lymphatics there are formed enlargements along their 
course, to constitute the farcy ^'buds.^^ These usually soon 
show suppuration. As a rule this form of the disease reaches 
a fatal termination in about two weeks. In the chronic form 
farcy shows localized tumors, which break down, sometimes 
forming deep ulcers. There is not much involvement of the 
lymphatics. The duration of this form of the disease may be 
for months or years. 

Glanders — diagnosis : The occupation of the patient — possi- 
bility of contact with diseased animals — may lead the phy- 
sician to suspect the disease in the presence of a nodular 
eruption or ozsena. 

Mallein, a product of the glanders bacillus, is used in the 
diagnosis of glanders, much as tuberculin is used in the diag- 
nosis of tuberculosis. This is of especial value when the 
disease is located in some recess of the body, as in the lungs, 
where it may not be brought under direct observation. 
Should mallein not be accessible, a male guinea-pig may he 
inoculated, or better several of them. The inoculation is 
made into the abdominal cavity. Two to five days after 
inoculation the testicles and their sheaths become swollen and 
purulent. 

Prognosis : Cases of acute glanders usually terminate fatally 
in about eight or ten days. Chronic glanders may last for 
months, and sometimes results in recovery. 

Glanders — prophylaxis: Diseased animals should be killed, 
and as far as possible individuals should be protected from 
the danger of inoculation. To this end, after death cremation 
of the bodies of both men and animals is advisable in all 
cases. 

Treatment : As far as possible, especially in early cases, the 



FOOT-AND-MOUTH DISEASE. 



91 



diseased tissue should be removed by the knife or cautery, 
and the parts treated antiseptically. 

The vakie of mallein as a therapeutic agent has not been 
definitely determined. 

FOOT-AND-MOUTH DISEASE. 

Definition : A disease, involving especially the mouth and 
extremities, sometimes the udder and teats, that occurs most 
frequently in cattle, sometimes in other animals, and is occa- 
sionally communicated to man through the ingestion of milk 
and other dairy-products from diseased animals, or directly by 
inoculation. 

Some believe that aphtha is an expression of this disease 
in man. 

Foot-and-mouth disease — symptomatology : Incubation, two 
to ten days. The chief prodromata are pains in the head and 
limbs ; /erer, 100° to 103° F.; malaise; vertigo; and fre- 
quently a sensation of formication in the hands and feet. An 
eruption then appears iijjon the mucous membrane of the mouth 
and nose, consisting of vesicles with at first clear contents, 
which later become turbid. The vesicles may burst and 
crusts form. There is swelling of the tongue, lips, nose, and 
eyelids. Often vesicles appear upon the fingers. An eruption 
of vesicles, discrete or confluent, may appear upon various 
parts of the body or become general. With appearance of 
the eruption the temperature usually falls. The affection of 
the mouth causes difficult deglutition and speech, sometimes 
difficult respiration. 

The disease may last from five to eight days in mild cases ; 
as long as eight weeks in severe cases. 

The principal complications are diarrhoea ; hemorrhages 
from the mouth, bowels, or kidneys; sometimes bronchitis 
and catarrhal pneumonia ; occasionally spasms and paralyses. 

Foot-and-mouth disease — diagnosis: The diagnosis rests on 
the evidence of direct or indirect transmission of the disease 
from infected animals, in conjunction with the symptoms of the 
disease. A positive diagnosis may be made by inoculating an 
animal, best a goat, with the contents of the vesicles from a 



92 



INFECTIONS. 



suspected case. As the name indicates, the disease is peculiar 
in that the eruption usually appears only upon the mouth and 
extremities. 

The differential diagnosis concerns chiefly other forms of 
stomatitis, scurv^y, measles, typhoid fever, septicaemia, and 
rarely syphilis. 

Prognosis : Usually good. Death may occur in delicate 
children, the aged, or individuals weakened by disease or 
other cause. 

Foot - and - mouth disease — prophylaxis : Diseased animals 
should be isolated. Individuals who have abrasions of the 
skin should not come in contact with diseased animals or in- 
dividuals. The dairy-products and meat from infected ani- 
mals should not be used, or should at least be subjected to 
sterilization by heat before being used. 

Treatment : Largely symptomatic. Siegel uses salicylate 
of sodium internally. Among the many remedies used locally 
are chlorate of potassium, borax, alum, lead, nitrate of silver, 
salicylic acid or zinc paste, dermol, creolin, lysol, and per- 
manganate of potassium. The patient should be kept com- 
fortable by the use of opium, best in the form of Dover's 
powder, chloral, the salicylates, and phenacetin. 

TYPHOID FEVER (Typhus Abdominalis; Enteric Fever; Ner- 
venfieber (German)). 

Definition : An acute infectious disease, due to a special 
bacillus, characterized by hyperplasia and ulceration of the 
intestinal lymph-glands (Peyer's patches), and enlargement of 
the mesenteric glands and of the spleen. Nervous symptoms 
are marked. There are headache and hebetude, a cloud about 
the brain, constituting the status typhosus. The disease 
shows more or less characteristic fever, eruption, stools, and 
meteorism. Sanarelli defines typhoid fever as an infection 
of the lymphatic system by the typhoid bacillus. 

History : First recognized as a separate disease by Pierre 
Bretonneau (1813); named Typhoide " by Louis (1829); 
separated from typhus fever by Gerhard, of Philadelphia 
(1837). The bacillus typhosus abdominalis was described by 
Eberth, and observed and photographed by Koch (1880). 



TYPHOID FEVER. 



93 



Etiology : The bacillus typhosus ahdominalis is generally 
recognized as the specific cause of typhoid fever. 

Typhoid fever seems to show preference for the temperate 
climate and prevails especially in the fall months. Hot, 
dry weather seems conducive to a dissemination of the dis- 
ease, probably through greater contamination of the water- 
supply. The bacillus of typhoid fever gains entrance to the 
body chiefly through the water-supply and milk. 

Typhoid bacilli, when mixed with fat, oil, or butter, are not 
killed by fresh gastric juice, and thus may pass into the in- 
testine. 

The disease occurs especially in youth and adolescence; 
rarely in infancy and age. 

Typhoid fever — symptomatology : Incubation, four to twenty- 
three days ; usually aboid two weeks. Often during incu- 
bation there are lassitude, early fatigue, and especially kick of 
concentration. 

The onset of typhoid fever is insidious. Among the pro- 
dromal symptoms are languor, headache, coated tongue, ano- 
rexia, nausea, epistaxis, pain in the bach and legs, sometimes 
in the abdomen ; chilly sensations, rarely rigor, and sometimes 
vertigo. These symptoms continue to increase until the 
patient is forced to his bed, which is usually reckoned as the 
first day of the disease. 

Often during the first week of the disease the temperature 
(Fig. 8) shows the so-called step-ladder rise, being a degree or 
more higher in the evening than the previous evening, and a 
degree higher in the morning than the previous morning, 
reaching by the fifth to the seventh day 103° to 104° F. 
The jmlse is quickened, 100 to 110, of full volume but low 
tension, sometimes becoming dicrotic. With the high fever 
there may be delirium. By the latter part of the first week 
the spleen is noticeably eidarged and the rose-colored lenticular 
spots are first seen on the skin, as a rule, in the region of the 
diaphragm. The tongue is coated white, with clean, bright- 
red margins and tip. There are usually meteorism and diar- 
rhoea, sometimes constipation. After the discharge of the 
normal contents of the intestine the stools assume the " pea- 
soup, ochre-colored^' appearance, sometimes colored with 



94 



INFECTIONS. 




blood. Blood may be found with the microscope in almost 
all cases. The urine is diminished in quantity, the urea 



TYPHOID FEVER. 



95 



Fig. 9. 




Typhoid bacilli from a section of the human spleen, tenth day of enteric 
fever (Charcot). 

increased, chlorides diminished, and frequently there is a 
trace of albumin. There may be a slight cough, a symptom 
of bronchitisy very early in the course of the disease. 



Fid. 10. 




Typhoid hacilli in a Peyer's patch before ulceration (Charcot). 



96 



INFECTIONS. 



During the second iveek the fever continues on a high plane 
with slight morning remissions. The other symptoms become 
more pronounced. The pulse varies, 90-120, and is less 
dicrotic. Headache gives way to mental torpor and dulness. 

Fm. 11. 



if 





Human liver, tenth day of enteric fever (Charcot), 



The tongue is dry and covered with sordes. Toward the end 
of this week there is danger of perforation and lieinoi-rliage. 

In mild, cases the symptoms may begin to improve by the 
end of the second week. 

As a rule the symptoms continue during the third iveek 
much the same as during the second week, only more severe. 
There may be low muttering delirium, stupor, coma-vigil, and 
picking at the bedclothes in bad cases. The emaciation and 
loss of strength are more marked. The fevei- shows greater 
morning remissions, a beginning lysis. Pulse, 110-130. 
During this week perforation and hemorrhage, bedsores, j^neu- 
monia, and heart-failure are the complications to be most 
feared. 

Usually during the fourth iveek the temperature reaches the 
normal by a gradual descent — lysis — and all the other symp- 



TYPHOID FEVER. 



97 



toms show improvement. In severe cases the picture presented 
during the third week may be continued into the fourth or 
even the fifth week, only becoming worse through the weak- 
ness of the patient. As a rule a marked improvement in the 
patient^s condition occurs during the fourth week and conva- 
lescence begins. With the beginning of convalescence the 
patient shows a considerable uicrease in appetite. 

The more important complications of typhoid fever are 
^perforation, peritonitis, hemorrhage, and parenchymatous de- 
generations of muscles. Thus the heart-muscle may be 
aff'ected so as to cause heart-failure ; or the diaphragm 
may be rendered incompetent. Many, if not most, cases are 
affected secondarily by septicmmia. 

Typhoid fever— diagnosis : In cases that come under obser- 
vation early the anorexia, headache, iveakness, epistaxis, 
diarrhoea, gradual rise of temperature, and roseola, and later 
tympanites and enlargement of the spleen, are usually sufficient 
for diagnosis in typical cases. 

The blood-test for typhoid fever (Widal test) is almost, if 
not absolutely, pathognomonic of infection by the typhoid 
bacillus. Unfortunately, the reaction is found sometimes for 
a long time after recovery from typhoid fever. Apple and 
Thornbury report a case in which the reaction persisted thirty- 
one years. But usually the reaction disappears within a year. 
The history should not be implicitly relied upon in excluding 
a previous attack, since typhoid fever may have been mis- 
taken for some other disease. Further, in a few instances 
infection by the typhoid bacillus has occurred in other parts 
of the body than the alimentary tract. But as a rule the his- 
tory is clear, and the blood-test remains the best single sign 
we possess. 

Method: The best and simplest way to make the test 
(Widal) is with dried blood. A drop of blood is collected, 
from the finger-tip or lobe of the ear, upon a piece of glass 
and permitted to dry. When the examination is to be made 
a particle of the dried blood is added to just sufficient water 
to cause indistinct coloring. Of this an ordinary platinum 
loopful is added to a similar quantity of an emulsion of the 
typhoid bacillus in a hanging drop under the microscope, 
7— P. M. 



08 



TNFECTrONS. 



Tlie culture of the typlioid haeilliis slioul'd be twelve to 
twenty-four hours old, made from a stock culture a month 
old. The emulsion of the typhoid bacillus is made by addin*^ 
to a dro]) of normal salt solution (O.G per cent.) a tra(;e of the 
(udture of the ty|)hoid biuiillus. 

Hcdvtiou : \\'hen diluted typhoid blood is added to an 
emulsion of the typhoid ba(;illus, the bacilli are observed 
under the microscope to become ai^olutinated together in 
little clumps, and to lose their motility. To be positive, the 
reaction sliouhl be present within lifteen minutes. 

Th(^ diazo-reaction of l^]hrlich does not fm-nish so reliable 
evidence as tiie blood-test, but is more readily made and often 
sheds a valuable side bght upon a doubtful case. The vcagodH 
necessary are (1) a 0.5 per cent, solution of sodium nitrite; (12) 
sulfanilic acid solution, composed of a 5 })er cent, solution of 
hydrochloric acid in distilUnl water and sulfanilic acid to sat- 
uration ; (3) ammonia. 

Method: To 3 c.c. of urine add one drop of the sodium 
uitritt; solution. Shake. Add o c.c. of the sulfanilic acid 
solution. Shake. Add an excess of ammonia. 

The i'C((ctio)i, when positive, is marked by a rose-red to a 
dark-red color, whic^h persists also in the foam. A brownish- 
yellow color is negative. 

Tn tyj)hoid fever the diazo-reaction is present from the 
mid(ll(» of the first week uj) to the ninth day and longer, but 
not after the third week. Al)sence of the reaction before 
the ninth day exchides typhoid fever, at least in an average 
or grave form. 

The typhoid bacillus may be isolated from the urinCj feces, 
or hlood, especially blood witlidrawn from the spleen, rarely 
from the rose-colored spots. But the withdrawal of blood 
from the enlarged and friable spleen, in which the bacilli 
may most frequently be found, is not without danger, through 
rupture of the spleen and hemorrhage. 

During the first week ty])h()id fever should be differentiated 
especitdly from febricula, infiuenza, and the exanthematous 
diseases common among children. \A^hen a case first comes 
under observation late in the course of the disease the differ- 
ential diagnosis concerns especially malaria, acute miliary 



TYPHOID FEVER. 



99 



tuberculosis, appendicitis, peritonitis, trichinosis, and, espe- 
cially in children, entero-colitis. 

Typhoid fever — prognosis : The treatment with cold baths 
has reduced the mortality from about 30 per cent, to about 
5 per cent. The mortality is especially high in the intem- 
perate, gouty, and corpulent. Recovery is the rule, with very 
few if any exceptions, in cases that are seen early and treated 
faithfully with the cold bath whenever the temperature 
reaches 103° F. in the rectum. The prognosis \\\\\ depend 
upon the height and duration of the fever, the presence of 
complications, the time the patient comes under treatment, 
especially the time the patient takes to his bed, and the degree 
of toxaemia, as manifested by the strength of the heart and 
the presence of nervous sym.ptoms. 

Prophylaxis : The ingesta, especially the milk and water, 
should be clean — i. e., not contaminated by the excreta of 
typhoid-fever patients. Or if such food and drink must be 
used, it should first be subjected to the temperature of boiling 
water. 

The excreta (stools and urine) of the patient should be dis- 
infected, best by fire, or carbolic acid (1 : 20), or bichloride 
of mercury (1 : 1000). Clothing contaminated by the dis- 
charges should be sterilized. 

Typhoid fever — treatment : Proper nursing is of the greatest 
value. The patient must remain in bed, and under no cir- 
cumstances arise from the recumbent posture until the tem- 
perature has remained normal at least three successive days. 
This implies the regular use of the bed-pan and urinal. The 
food should be fluid, chiefly milk, which may be given raw or 
boiled, hot or cold, sometimes coagulated with rennet or in the 
form of koumyss, kephir, or matzoon ; occasionally buttermilk 
or wine-whey, milk-punch, or egg-nog. The milk-diet may 
be varied with clear soups and broths, made from beef, mut- 
jl ton, veal, or chicken ; or consomme, with or without vegeta- 
I bles, rice, or barley, carefully strained. The patient may 
1 receive also oyster-soup, clam-juice, strained barley-gruel, and 
meat-juice. At any rate, the diet must be liquid. To guard 
against continued infection, it may be necessary to boil the 
water and milk or to secure these articles from a difi'erent source. 



100 



INFECTIONS. 



The patient should be placed under good hygienic sur- 
roundings, with plenty of fresh air and sunshine, and secluded 
from society. During convalescence the visits of friends may 
at first be limited both in number and duration. Throughout 
the illness small quantities of food and drink should be offered 
at definite intervals, usually every two or three hours. 

Of drinks pure water is best, sometimes in the form of iced 
tea, lemonade, or barley-water. At times the juice of an 
orange or lemon is very grateful. 

Various specifics have been recommended from time to 
time ; among them guaiacol, calomel, bichloride of mercury, 
carbolic acid, sulphuric acid, iodine, chlorine, quinine, salol, 
the salicylate of bismuth, boric acid, turpentine, oil of euca- 
lyptus, thymol, camphor, and beta-naphthol, but none of 
these has been generally accepted. 

Early in the course of typhoid fever it is best to administer 
calomel or castor-oil to empty the intestinal tract, especially 
when there is constipation. 

In the way of specific medication, the transfusion of blood 
from convalescents has been practised by Hammerschlag ; 
injections of blood-serum from convalescents by Hughes and 
Carter ; the serum of animals rendered immune through inocu- 
lation by Beumer and Peiper (sheep) ; and Klemperer and 
Levy (dogs), with results sufficiently satisfactory to call for 
further experimentation along this line. 

Frankel and Manchot, in fifty-seven cases, obtained prom- 
ising results by injection of sterilized thymus bouillon- 
cultures of the typhoid bacillus deep into the muscles of the 
back. The cases in which the injections were continued 
showed an amelioration of the constitutional symY)toms, with 
an early fall of temperature, increase in the quantity of urine, 
and a cessation of diarrhoea. Rumpf reported somewhat 
similar results in the treatment of thirty cases of typhoid 
fever with similar cultures of the bacillus pyocyaneus. 

Loss of appetite and strength may be met probably best 
with the tincture of nux vomica before meals. In the pres- 
ence of fever the gastric juice is not formed so readily, and it 
is best to give dilute hydrochloric acid after meals. 

Slight fever may be let alone; higher fever, above 103° F. 



TYPHUS FEVER. 



101 



in the rectum, calls for the cold bath, which lowers the tem- 
perature and strengthens the heart. The bath should be at a 
temperature of 68° F. ; or may be begun at a higher tempera- 
ture and gradually lowered. The duration of the bath (five 
to twenty minutes) must be sulJicient to lower the temperature 
of the patient two degrees. The bath may be repeated every 
two hours should the temperature reach 103° F. in the rectum. 

Cold sponging, the application of cold compresses or of 
ice, the cold pack, etc., are poor substitutes for the cold bath ; 
but are often useful. Beneficial results may sometimes be 
obtained by the judicious employment of antipyretic drugs, 
of which lactophenin is probably the safest. 

Tympanites and abdominal pain may be relieved by tur- 
pentine stupes. For meteorism, in the presence of a dry 
tongue, sordes, and muttering delirium, turpentine may be 
given internally or by enema. 

Excessive diarrhoea — more than three or four stools a day — 
may be controlled by enemata of starch and opium, or the 
administration per os of bismuth and Dover's powder, or a 
combination of tincture of opium, hydrochloric acid, and cam- 
phor-water. Constipation may be relieved by enemata re- 
peated every three or four days if necessary. 

Hemorrhage calls for absolute rest, restricted diet, ice both 
internally and externally, the administration of opium and 
acetate of lead. Collapse may be met by the injection of 
the physiological salt solution, 0.6 per cent., into a blood- 
vessel, the rectum, or the subcutaneous tissue. 

For peritonitis morphine may be given hypodermatically. 
Perforation may demand laparotomy, which has saved three 
cases out of seventeen reported. 

AYeakness of the heart calls for stimulation with alcohol or 
digitalis internally ; camphor, strychnine, or ether hypoder- 
matically, to bridge an impending collapse. 

During convalescence, after the temperature has been normal 
ten days, the patient may gradually return to a solid diet. 

TYPHUS FEVER (Typhus Exanthematicus). 

Definition : An acute infectious disease, probably due to a 
specific micro-organism, characterized by sudden onset, a 



102 



INFECTIONS. 



peculiar eruption, which is usually present, and, as a rule, 
termination about the fourteenth day by crisis. 

History : " Typhus fevers " were recognized by the older 
clinicians ; but they did not separate typhus fever from a 
number of other fevers, notably typhoid fever and relapsing 
fever. Typhus was differentiated from typhoid fever by 
Gerald and Pennock, of Philadelphia (1836), and the non- 
identitv of the diseases confirmed by Jenner, of London 
(1849-51). 

Etiology : Various micro-organisms have been found in 
typlius fever, but none of them has been proven to be the 
cause of the disease. Balfour and Porter found a diplococcus 
in several cases post-mortem ; and in fifteen out of nineteen 
cases of typhus fever examined during life, in which the diplo- 
coccus was the only organism present. 

Among the predisposing causes are overcrowding, bad ven- 
tilation, poverty, famine and scarcity of food, and intemper- 
ance. 

Typhus fever — symptomatology : The period of incubation^ 
variously given at from a few hours fHuss) to as long as 
thirty-one days (Hutchinson), is usually about twelve days. 

The invasion is short, one to three days, and abrupt, begin- 
ning with chilly sensations, sometimes with a distinct chill. 
There are malaise, later great prostration, headache, vertigo, 
anorexia, general soreness of the body, and pains in the loins 
and extremities, especially the lower extremities. The tongue, 
large and pale, presents at first a w^hite coat, which later 
becomes darker in color. The face is flushed and dusky ; 
the conjunctivse show a well-marked uniform congestion. 
Usually the hands show tremor. The urine is small in quan- 
tity and high-colored, specific gravity possibly 1030. The 
temperature reaches 102°-105° F. within a day. The pulse is 
rapid and compressible. Usually the abdomen presents noth- 
ing abnormal. Constipation is the rule. Sometimes there is 
nausea, more rarely vomiting. 

The eruption appears on the third, sometimes as late as the 
sixth day, first as a dark punctcde measly rash, which disap- 
pears on pressure, to reappear when the pressure is removed. 
The eruption is found first upon the abdomen, later on the 



TYPHUS FEVER 



103 



arms and thighs, more rarely on other parts of the body, the 
face, and neck. An eruption under the skin, in addition to 
the rash just referred to, constitutes the mulberry rash of 
Jenner. 

Later, about the fifth day, the measly rash becomes darker 
in color and does not disappear on pressure, due to capillary 
hemorrhage and the deposit of pigment. About the tenth 
day true petechke appear, which do not disappear after death. 
The eruption usually disappears in eight or ten days. 

The temperature rises rapidly during the first week, often 
reaching 103° F. or more in a day or two, and remains high, 

Fig. 12. 



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103' 
102' 
lOf 
100' 

98 



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3 


4 


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9 


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Typhus fever. 

sometimes with gradual descent, until abotit the end of the 
second week, when the temperature drops suddenly, by crisis, 
to normal or subnormal. In uncomplicated cases a remission 
occurs early in the second week. As in typhoid fever, the 
temperature in typhus fever shows a slight diurnal variation. 

Diagnosis : The knowledge of the existence of the disease 
in the neighboi-hood is of value. Isolated cases may present 
great difficulties in diagnosis, especially in the absence of 
eruption. The sudden onset, great .jjrostration, with the dense 



104 



INFECTIONS. 



cloud about the brain, and jjeculia^' e7%iption, appearing about 
the third day and sparing the face, and the a-ms at the end 
of the second week, are characteristic. 

Typhus fever should be differentiated especially from 
typhoid fever, cerebro-spinal meningitis, pneumonia, small- 
pox, uremia, and severe cases of yellow fever. 

Prognosis: Children rarely die of typhus fever; the mor- 
tality among the aged and intemperate is high. Different 
epidemics have given a mortality of from 12 to 20 per cent. 
Much depends upon the strength of the heart and the degree 
of toxjemia. 

Prophylaxis : There should l)e early isolation of typhus 
fever patients, and later thorough disinfection, with lire, for- 
maldeliyd, bichloride of mercury, or sulphur, of the room and 
of all articles with which the patient came in contact. 

Treatment : The treatment' of typhus fever is nuich the 
same as of typhoid fever. Special stress should be laid on 
hydrotherapy, especially cold baths. The heart nuist be 
supported, best with alcohol, digitalis, and nitroglycerin. 

RELAPSING FEVER (Recurrent Fever). 

Definition : An acute infectious disease, caused by the 
spirochmta Obermeieri, characterized by an intermission at the 
end of the first week, with the disappearance of the fever and 
symptoms, followed by one or more relapses. 

Etiology: The specific infectious agent of relapsing fever is 
the spirochsete (spirillum) discovered by Obermeier, in the 
blood during fever, in 1873. Relapsing fever is contagious 
directly and possibly indirectly through fomites. The predis- 
posing causes are similar to those in typhus fever. 

Relapsing fever — symptomatology : Incubation one to four- 
teen days, usually jive to seven days. For a day or two there 
may be anorexia, lassitude, headache, and vertigo. 

Invasion as a rule is abrupt, with a chill followed by a rise 
of temperature, frequently 104° F., which in a day or two 
reaches 105^-106°. The' pulse becomes rapid, 110-130, full 
and strong. The spleen shoivs early enlargement. There are 
giddiness, headache, and severe pain in the muscles of the 



RELAPSING FEVER. 105 

trunk and extremities, especially in the calves of the legs. 
Some cases begin with nausea and vomiting. 

The face is flushed, the tongue coated white. The patient 
complains of thirst. Often there is jaundice. Some cases 
show an eruption of petechise. The urine is scanty, dark 
colored, albuminous, with high specific gravity, containing 
bile when there is jaundice, sometimes blood. 

With the crisis the temperature falls suddenly to normal or 
subnormal. The pulse drops to 70 or less. Often just before 



Fig. 13. 




Relapsing fever (MurcMson). 



the crisis the temperature becomes higher and there are sweat- 
ing, diarrhoea, and epistaxis, sometimes an appearance of the 
menstrual flow, sometimes delirium. 

Rarely does convalescence proceed uninterruptedly. As a 
rule about a week, four to fourteen days, after the crisis there 
is a relapse, resembling the original attack, but somew^hat 
shorter in duration, the second crisis appearing usually in 



106 



INFECTIONS. 



three to five days. Recovery may now take place, or there 
may be as many as three or even four relapses. 

Diagnosis : The diagnosis of relapsing fever rests upon the 
discovery of the spirochceta Obermeieri, which is found upon 
microscopic examination of the fresh blood during the fever. 



Fig. J 4. 




Spirocheetes of relapsing fever in the blood. 



Differential diagnosis ^ especially during the onset of the 
disease, concerns typhus fever, yellow fever, and smallpox. 
Cases seen later may be confounded with typhoid fever. 

The intermissions and relapses are characteristic. 

Prognosis : Death rarely occurs, except through collapse or 
complications, especially pneumonia. 

Treatment : Lowenthal treated 131 cases of relapsing fever 
with antispirochcetiG serum. Thirty-four of the cases were 
thoroughly treated, with but one death. Compared with 152 
cases not subjected to specific treatment, the use of the serum 
lowered the mortality about one- half, markedly lessened the 
number of relapses, and shortened the duration of the dis- 
ease. 

Symptomatic treatment: Pain may call for opium; a threat- 
ened collapse for stimulants — alcohol, camphor, ether, strych- 
nine, ammonia, digitalis. 



YELLOW FEVER. 



107 



YELLOW FEVER. 

Definition : An acute infectious disease, caused by a specific 
micro-organism, characterized by icterus and hemorrhage from 
the mucous membranes. 

Etiology: The specific infectious agent is the bacillus icfe- 
roides (Sauarelli), which resembles closely and is possibly 
identical Avith the micro-organism described by Sternberg as 
the bacillus X. 

The bacillus icteroides is a slender bacillus, 2-4 long, 
motile, ciliated, facultative, anaerobic. The bacillus is decol- 
orized by Gram's method, grows in the usual culture-media, 
causes fermentation when grown upon a culture-soil contain- 
ing sugar, and is pathogenic, producing in man, monkeys, and 
dogs the symptoms of yellow fever. In many cases the ba- 
cillus is not found, probably because it is overrun by sec- 
ondarv infection, especially by the pyogenic streptococci and 
staphylococci. The bacillus seems to thrive better and show 
greater virulence in the presence of a certain fungus, an asper- 
gillus. This fungus thrives imly in warm weather, which 
may explain the prevalence of yellow fever during the warm 
season (Lacerda). 

The bacilli occur in small numbers, but produce a powerful 
toxin, the aniaril poison of Sauarelli. 

Yellow fever prevaih especially along the sea-coasts and 
prefers unsanitary conditions and a hot climate. The bacillus 
icteroides resists well both drying and the action of sea water, 
and its growth seems to be favored by the moulds. One 
attack of yellow fever usually confers immunity. 

Yellow fever — symptomatology : Incubation lasts from a few 
hours to five days. Preceding the attack there may be some 
malaise, anorexia, lassitude, headache, vertigo, and indisposi- 
tion, both physical and mental ; or all these symptoms may be 
entirely absent. As a rule the attack begins suddenly with a 
chill or chilly sensations. Sometimes the onset is insidious. 
There are fever and more or less pain in the head, esjjecially in 
the fronted and supraorbitcd regions. The eyeballs are painful, 
and there may be photophobia. The patient complains of 
'pains in the loins and ccdves of the legs. After the chill the 



108 



INFECTIONS. 



temperature rises rapidly. The face is flushed, often con- 
gested and swollen. The conjwictivce are injected. The skin 
is dry and hot, and there may be considerable restlessness and 
jactitation. 

Typical eases usually present three stages. The first stage 
begins with the initial paroxysm and lasts tw^o to five days. 
This stage includes the high temperature, which is usually 
highest on the first day. The second stage, beginning after 
the fall in temperature, shows often subnormal temperature 
and great prostration, lasting a few hours or days. The third 
stage is the period of convalescence, during the early part of 
which there is a remittent fever. 

Jaundice, which is not present in all cases, begins toward 
the end of the first stage, is most intense during the second 
stage, and may last far into convalescence. Sometimes jaun- 
dice does not begin until the second or third stage, when 
it usually lasts longer. The urine, scanty and high-col- 
ored, early shows albumin. There may be urceuiia. There 
are gastric distress, vomiting, and hsematemesis (black 
vomit), due to toxaemia. Sometimes the " black vomit ^' is 
absent throughout the course of the disease, even in severe 
cases. 

Yellow fever — diagnosis : In the blood-test, with the bacillus 
icteroides, the reaction of paralysis and agglutination is pres- 
ent as early as the second day of tlie disease. Albuminuria 
is usually present by the third or fourth day, and with the 
temperature and pulse is of value in diagnosis. Later the 
appearance of icterus, without enlargement of the spleen, 
helps in differentiation. The history of the patient, especially 
regarding the place of residence and absence of previous attack, 
and the knowledge of the j)resence of an epidemic, may aid 
in the individual case. 

The prognosis of yellow fever is more favorable among the 
natives of regions where the disease exists continuously than 
among those not " acclimatized,'' and is better for women and 
children than for men. The prognosis may said to l)e favor- 
able when the temperature does not rise above 103° F. by the 
end of the second day, and assumes gravity in proportion to 
the height of the fever at this time. The mortality varies in 



YELLOW FEVER. 



109 



cliiferent epidemics. The majority of deaths occur during the 
first week of the disease. 

Yellow fever — prophylaxis : Patients should be isolated. 
The excreta, and all articles coming in contact with the patient, 
should be thoroughly disinfected, best by fire. Susceptible 
individuals, as far as practicable, should avoid infected re- 
gions. 

Yellow fever — treatment: Fitzpatriek (LS99), working at 
the instance of Doty, injected horses with the filtrate of cult- 
ures of the bacillus icteroides. The blood-serum of the 
horses was then found to prevent the lethal effects in guinea- 
pigs of inoculations with the bacillus icteroides, that jDroved 
fatal in control-animals. 

Early in the course of the disease, best on the first day, 
the use of a cathartic is recommended, preferably castor oil, 
calomel, or a saline cathartic. Fever may call for the ex- 
ternal application of cold water and evaporating lotions so 
long as the skin is hot and dry and the temperature elevated 
(Sternberg). Later tepid water should be used. A hot mus- 
tard foot-bath may be repeated several times during the first 
day. Cold enemata are recommended. The patient should 
be protected from cold draughts or sudden lowering of tem- 
perature. During the height of the fever antipyrin may be 
advantageously given. Aconite has been recommended dur- 
ing the first day or two of the disease. Later digitali- may 
be used, with acetate of potassium or ammonium (Bemisj, or 
sodium bicarbonate in ice-cold water (Sternberg). 

The acid secretions would seem to call for the use of 
alkalies. The following alkaline and antiseptic mixture, pro- 
posed by Sternberg, has been largely used : 

Sodii bicarbonatis, 10.00. 
Hvdrargvri chloridi corros., 0.02. 
Aquffi pur^e, 1000.00. 
Sig. — Two or three tablespoonfuls every hour ; 
to be given ice-cold. 

A weak heart calls for stimulation. Stimulants, as a rule, 
need not be given before the fourth day, and then they must 
be administered in small quantities in order not to cause vom- 



110 



INFECTIONS. 



iting. Chanrpagne, brandy, later milk punch, English ale, 
and Rhine wine may be used. 

During the height of the fever no food is required. With 
the fall of temperature there is usually a return of the appe- 
tite. The diet should then consist of milk in small quantities, 
possibly with lime-water, and chicken-broth, which may be 
given every two hours. Excessive vomiting may demand 
rectal alimentation. The return to the normal diet should be 
gradual. 

CHOLERA (Asiatic Cholera; True Cholera). 

Definition : An acute infectious disease, caused by the 
spirillum cholerce Asiaticce, characterized by onset with diar- 
rhoea and vomiting, later showing great prostration, severe 
cramps or spasmodic contractions of the muscles, with char- 
acteristic stools, resembling rice-water, and a cyanotic appear- 
ance of the skin. 

History : In the southern part of Bengal cholera is 
endemic. From this region epidemics of cholera have in- 
vaded Asia, Africa, Europe, and America. Cholera was 
described in India several centuries before Christ, by Charaka 
(Macnamara). Koch believes, however, that true cholera was 
not endemic in India before 1817, although epidemics of 
cholera, or a disease resembling cholera, are recorded as early 
as 1543. 

Cholera first reached the United States in December, 1832, 
by way of Quebec and New York. The disease appeared 
again "in 1835-6; 1848; 1849; 1854; 1866-7 and 1873. 
Since then emigrants from Europe have brought cholera to 
America, but quarantine has prevented the disease becoming 
epidemic. 

The spirillum cholerce Asiaticce was discovered by Koch 
(1884). 

Etiology : Asiatic cholera is now generally recognized as a 
water-borne disease (Hart), due to the spirillum cholerce 
Asiaticce, the "comma bacillus'^ of Koch. The spread of the 
disease is favored by bad hygiene, especially poor sewerage. 
Cholera is contagious through the ingestion of the excreta of 
infected cases. The disease shows a preference for age, and for 



CHOLERA. 



Ill 



individuals debilitated by disease or intemperance. The river 
population, those who work and live on the water, are pre- 
disposed to infection. Epidemics of cholera avoid cold 
weather. 

Cholera — symptomatology: Incvhatlon. one to five days. 
Often cholera htgiu-^ vith (Uarrlt^rn, sonietima- accompanied by 
vomiting, frequently ci)n]ing on during the night. There are 
pain in the abdomen, headache, and depression. These symp- 
toms increase in severity. Diarrlirea may b'e severe in the 
beginning, with pain and tenesmus. The patient suffers 
cramps in the calves of the legs, later in the arms and abdomen. 
There is great prostration. Y( uniting may be more or less 
continuous. The stools, at first nuico-purulent and stained 
with bile, early assume the rice-water character. The sl:in is 
cyanotic and cold. There are extreme <i,i.r/f ///. fhi/'sf, -ometimes 
heart-failure. These symptoms continue from a few hours to 
a day. Sh<juld the patient survive this stage, a reaction sets 
in, the cyanosis disappears, the skin l)ecomes warm, the 
diarrhoea improves, and the prostration is relieved. There is 
always danger of relapse. 

Cases of cholera, showing various degrees of severity, have 
been called choleraic diarrhren, c-holerine, and cholera gravis. 

Diagnosis : The knowledge of the prevcdence of the disease, 
or of exposure to thr possibility of infection, is of value in 
diagnri-i^. which can Ije made positive by finding the spir- 
illuin r/iol' /''j: Asiafir/r in the stools in a case presenting the 
symptoms of cholera, which are indicative of intense intoxi- 
cation. 

Bacteriological examination : A hanging-drop or cover-glass 
preparation made from the suspected excreta may reveal the 
presence of spirilla. The cholera spirillum is motile, decolor- 
ized by Gram's method, and stains with the ordinary dyes, 
probably best Avith a solution of fuchsin. Upon the surface 
of diluted bouillon in the incul)ator culonies appear in ten to 
twelve hours as a wrinkled film. Gelatin in plates, Petri 
dishes, or tubes, may be inoculated both from the excreta and 
from the bouillon cultures. The gelatin begins to be fluidified 
in a day, and pre.^nts under the lens an appearance as if the 
surface were strewn with o;lass. The a^elatiu tubes show a 



112 



INFECTIONS. 



distinct funnel shaped depression, with the apex downward, 
from the flu id ifi cation of the gelatin. The so-called cholera 
red " or indol reaction may be obtained by adding to bouillon 
cultures that have been in the incubator ten to twelve hours, 
or to gelatin cultures in which fluidification has occurred, pure 
sulphuric acid. A reddish-violet or purplish-red color quickly 
appears. Cultures in litmus bouillon, made in the incubator, 
show decolorization within a day. 

Pfeiffer has shown that when a trace of cholera serum is 
added to a culture of cholera spirillum and injected into the 
peritoneal cavity of a guinea-pig, or when the spirilla are 
injected into immunized guinea-pigs, the (;holera vibrios are 
quickly destroyed. This is the so-called Pfeiffer phenomenon. 

Blood-test: The blood of cholera patients causes paralysis 
and agglutination of the cholera spirilla (see Typhoid Fever). 
This method promises to be of value both in the diagnosis of 
cholera and in the differentiation of the cholera spirillum from 
si nui 1 ati n g o rgan i s m s . 

The prognosis of cholera, which should always be guarded, 
depends largely upon the gravity of the symptoms. Com- 
plication with pregnancy, abortion, pneumonia, or typhoid 
fever, makes the outlook more grave. 

Prophylaxis demands quarantine at sea of infected indi- 
viduals, the destruction of the stools in all cases, best by 
heat, and the abandonment of contaminated water-supplies. 
Water may be safely used if thoroughly boiled. The patient 
must be isolated and all articles that come in contact with 
him should be sterilized. 

Cholera — treatment : W e know no specific. We may look 
for advance in this direction, above all, to modern bacteri- 
ology (Rumpf). The mortality was decreased in a series 
of 193 cases of cholera treated in Japan, by Nahagawa, with 
Kitasato's cholera antitoxin. Klebs's anticholerin has been 
tried with results that would seem to justify a further trial 
of the remedy. 

Cases of cholera without marked symptoms need little or 
no treatment, aside from prophylactic measures. Diarrlioea 
calls for rest in bed and the use of opium. 

In cases threatened with cyanosis, Reiche injected hypo- 



CHOLERA MORBUS. 



113 



dermicallv the fluid extract of opium with good results. The 
intestinal canal should be emptied with castor oil, or possibly 
better with calomel, which has the advantage that it may at 
the same time exert some antiseptic influence. As a rule 
purgation may be continued only a day or two. Cantani 
(1870) introduced the use of tannic acid enteroclysis. The 
intestine is irrigated several times a day with one or two 
quarts of a 1 per cent, solution of tannic acid at 104° F. 
This method has been modified by v. Genersich, in what he 
calls diaclysmus, using from five to fifteen quarts of a 0.1 per 
cent, to 0.2 per cent, solution of tannic acid at about 104° F. 
The fluid is gradually passed per rectum until there occurs 
copious vomiting of the irrigating fluid. Remarkable results 
are claimed for this method, which would seem to be justi- 
fiable in very severe cases. 

Vomiting may be controlled by cocaine, or better by mor- 
phine hypodermatically. 

Elimination by the skin, as well as warmth, may be secured 
by the use of the warm bath, the temperature of which may 
be increased to 113° F. for fifteen minutes. Three or four 
ounces of mustard may be added to the water. Should the 
pulse not show improvement or should syncope supervene, 
the bath must be discontinued. In most cases the bath does 
good. Drink in the form of hot or cold water should not be 
denied the patient. Alcohol in small quantities may do some 
good, but in large quantities acts unfavorably. 

Evidence of cardiac weakness calls for subcutaneous or 
intravenous infusions of normal salt solution, 0.6 per cent., 
or the use of camphor in oil, 1 : 8 or 1 : 10, internally or hypo- 
dermatically. 

CHOLERA MORBUS (Cholera Nostras; Cholera Infantum). 

Definition : An acute infectious disease, occurring especially 
during the simimer in temperate climates, characterized by 
diarrhoea and in severe cases presenting symptoms identical 
with those of true cholera. 

Etiology: The disease is due largely to the absorption from 
the alimentary canal of toxic substances, the result of the 
8— P. M. 



INFECTIONS. 



action of bacteria. A number of micro-organisms have been 
isolated from the stools. Among other bacteria, spirilli have 
been found, but not the spirillum cholene Asiaticae. Indis- 
cretions in diet are predisposing causes. The disease shows 
a preference for summer-time, in temperate regions. 

Cholera morbus — symptomatology : The symptoms vary 
from a simple diarrhoea to severe diarrhoea, sometimes with 
rice-water stools, vomiting, cramps, cyanosis, collapse, possibly 
death. 

Diagnosis : Cholera morbus is to be differentiated especially 
from true cholera (Asiatic cholera). Young children seem 
to be more susceptible to cholera morbus than to cholera 
Asiatica. The persistence of normal stools in severe cases 
would point to cholera morbus rather than to cholera 
Asiatica, in which we usually find rice-water discharges. 
Cholera morbus may so closely resemble true cholera that 
the differential diagnosis can be made only by bacteriological 
methods (see Cholera). 

Cases may simulate poisoning by arsenic, solanine, and 
colchicine, when the differential diagnosis may be made by 
a chemical examination of the contents of the stomach. 

Prognosis : Usually good. The mortality is greatest in 
children and among the aged, invalids, and intemperate. 

Cholera morbus — treatment : OflPending material should be 
removed from the alimentary canal. Material remaining in 
the stomach may be removed by lavage. Usually the 
material has passed into the intestine before the patient is 
seen by the physician, when it may be removed by the 
administration of castor oil, or calomel, gr. iij for an adult, 
gr. for children, in one dose or repeated. In cases of 
persistent vomiting it may be prudent to wash out the intes- 
tine with water, to which may be added soap, castor oil, 
sweet oil, glycerin, .^iij-vj, or tannin, 1:1000, best by means 
of the rectal tube. Obstinate vomiting may sometimes be 
relieved by enemataof chamomile tea, 80 c.c. to 100 c.c, con- 
taining tincture of opium, gtt. v (Liebermeister). Vomiting 
may usually be stopped by swallowing pieces of ice or by 
the administration of chloral. 

In general the treatment is the same as for true Asiatic 



ANTHRAX. 



115 



cholera (see Cholera). Severe cases may call for salt water 
infusion. 

ANTHRAX (Malignant Pustule; Carbuncle; Wool-sorters' "Disease ; 
Splenic Fever; Milzbrand (German) ; Charbon (French)). 

Definition : An acute infectious disease, caused by the bacillus 
anthracls, occurring among animals, especially cattle and 
sheep, and occasionally in man through accidental inoculation. 

Etiology: The specific infectious agent is the bacillus 
anthracis. The bacillus anthracis — Milzbrand bacillus (Ger- 
man), Bacteridie du charbon (French) — is 1-1. 25« broad 
and 5-20^M h>ng, sometimes growing into long filaments in 
favorable culture-soil. The ends of the bacilli are concave, 
so that when joined together, end to end, there is a distinct 
lenticular interspace between the bacilli. The bacillus is 
non-motile, forms spores, stains with the usual dyes and by 
Gram's method, and grows upon the usual culture-media. 

Gelatin is liquefied. The bacillus does not seem to be 
strictly aerobic, since a growth takes place all along the line 
of inoculation in stick-culture. The spores are very resistant 
to drying, and may be preserved in a dry condition for years 
without losing their vitality or virulence. A dry temperature 
of 140° C. will kill them in three hours (Koch and Wolff hiigel) ; 
or moist heat at the boiling-point, 100° C, in four minutes 
(Sternberg). The bacilli, in the absence of spores, may be 
destroyed by a temperature of 54° C. in ten minutes (Chauveau). 

^Yhen ingested the bacilli are killed by the gastric juice ; 
but when the spores are ingested they resist the action of the 
gastric juice and almost invariably cause infection. 

The action of the bacillus is due largely to a toxin. Martin 
made a chemical study of filtered cultures of the anthrax 
bacillus and found: (1) protoalbumose, deuteroalbumose, and 
a trace of peptone ; (2) an alkaloid ; and (3) small quantities 
of leucin and ty rosin. 

Cattle and sheep are infected by the ingestion of spores. 
Spores are not formed in the body, but only during the 
saprophytic existence of the organism. The soil becomes 
infected largely through the discharges of infected animals. 



116 



INFECTIONS. 



Animals or men (wool-sorters' disease) may be infected 
through the respiration of air containing anthrax spores sus- 
pended in the form of dust. Exceptionally infection may 
pass from the mother to the foetus, possibly through some 
lesion of the placenta. 

Man is infected chiefly through contact with diseased 
animals^ either alive or dead. Thus anthrax is found most 
frequently among butchers, liverymen, shepherds, tanners, 
wool-sorters, glue-makers, etc. Insects have been accused of 
spreading the infection, and the disease has been a(!tually pro- 
duced by inoculation with the stomach, legs, and feelers of 
carnivorous flies (Bollinger, Raimbert, and Davaine). 

Anthrax — symptomatology : Two general clinical forms of 
anthrax are recognized : (1) external anthrax, including malig- 
nant pustule and anthrax oedema ; (2) internal anthrax, 
including pulmonary and intestinal infection. 

Malignant pustule appears especially on the hands, arms, or 
face, surfaces most exposed to infection. Within a few hours 
after exposure there are itching and uneasiness, sometimes 
tickling, burning, stinging, at the point of inoculation, and 
soon there appears a small papule, which later becomes a 
vesicle. The vesicle bursts, discharging a bloody fluid, pre- 
senting the appearance of a red papule with a reddish-brown 
or black central crust. In mild cases the vesicle may dry up 
and disappear in a few days. In severe cases the inflamma- 
tion and induration become extensive, the inflammation involving 
neighboring lymphatics. At first there is fever; later the 
temperature becomes less elevated, often subnormal. The 
case may end in death in three to five days. Recovery is 
possible. 

Anthrax oedema is characterized by extensive oedema of the 
eyelids, head, hand, and arm, resulting in gangrene. The 
papilla and vesicle are absent. 

The pulmonary form of anthrax is commonly known as 
wool-sorters' disease and rag-pickers^ disease. The infection 
probably takes place from inhalation of dust containing an- 
thrax bacilli or spores. The attack comes on with cMll, pros- 
tration, pains in the back and legs, and fever (102°-103° F.). 
The pulse is rapid and feeble. Rapid breathing and pain in 



ANTHRAX. 



117 



the chest are prominent symptoms. Death may close the 
scene within twenty-four hours. 

The intestinal form of anthrax occurs usually through the 
ingestion of infected milk. Wool-sorters' disease sometimes 
shows atfection of the intestine^ probably through swallowing 
dust ladened with anthrax bacilli. The attack begins with a 
chill, with later vomiting, diarrhoea, fever, pains in the back 
and legs. There may be dyspnoea, cyanosis, restlessness, 
anxiety, and eyen conyulsions and death. There is enlarge- 
ment of the spleen; sometimes hemorrhage from mucous mem- 
branes. The skin may show petechi^e or phlegmonous inflam- 
mation. 

Aflection of the brain is rare. 

Anthrax — diagnosis : Knowledge of the occupation of the 
indiyidual, in a suspicious case, is an aid in diagnosis. The 
bacillus a nth rac is may he found m the pustules ; later in the 
blood. The bacillus can be separated by inoculation, best of 
a mouse or guinea-pig. In intestinal or pulmonary anthrax 
the bacilli may be found in the faeces or sputum, respectiyely, 
before they appear in the blood. 

Prognosis : Graye. Usually good results may be secured in 
cases of external anthrax that come under treatment early. 
The outlook is bad in late cases of external anthrax and in all 
cases of internal anthrax. 

Prophylaxis calls for the ayoidance of the cause (see etiology). 
Peterman (1892) injected into the yeins of a susceptible 
animal large quantities of a culture of the anthrax bacillus in 
ox-serum filtered through porcelain, and thus obtained tem- 
porary immunity lasting not longer than a month or two. 

Anthrax — treatment : The point of inoculation should be 
treated with caustics or the cautery. The pustule may be 
excised, or incised, and dressed with strong antiseptics. Men- 
thol, 2 per cent, solution in alcohol, applied on a gauze strip, 
with which the cayity may be packed after cleansing as thor- 
oughly as possible, has been found yery efPectiye (Braun). 
The cayity is packed with the saturated gauze, then coyered 
oyer air tight, and a compress applied. The gauze is left in 
twenty-four to forty-eight hours. Subcutaneous injections 
of solutions of bichloride of mercury or carbolic acid around 



118 



INFECTIONS. 



the pustule, repeated two or three times a day, are recom- 
mended. 

In internal anthrax active purgation may be resorted to, 
and quinine is recommended ; but treatment is of little avail. 

TETANUS (Lockjaw; Trismus; Opisthotonos ; Wundstarrkrampf 

(German)). 

Definition : An acute infectious disease, caused by the 
tetanus bacillus, characterized by tonic spasm of certain mus- 
cles, marked by trismus and opisthotonos. 

Etiology : Due to infection by the bacillus tetani. The 
tetanus bacillus appears to be a widely distributed micro- 
organism in the superficial layers of the soil in temperate and 
especially in tropical regions (Sternberg). Inoculation occurs 
chiefly through traumatism, especially wounds, however slight, 
caused by splinters or nails contaminated with earth or manure. 
The tetanus bacillus is attenuated by exposure to oxygen and 
sunlight, and the virulence is increased by passage through 
the intestines of animals. The more virulent tetanus bacilli 
are found in the superficial soil that comes in contact with 
the dung of animals. 

Asepsis and antisepsis has diminished the number of cases 
of tetanus after surgical operations. Not infrequently tetanus 
occurs after lacerated wounds. The wound through which 
the tetanus bacillus gains entrance to the body may heal 
before the disease is recognized, constituting cryptogenetic or 
" idiopathic " tetanus. So-called idiopathic tetanus is much 
less frequent than tetanus neonatorum. Other varieties of 
tetanus are puerperal, rheumatic, and traumatic. 

The spores of the tetanus bacillus are very resistant. Hen- 
rijean, quoted by Park, caused tetanus experimentally in an 
animal by inoculation with a piece of splinter which eleven 
years before had caused the disease. 

The symptoms of tetanus are due to the toxins of the teta- 
nus bacillus rather than to the bacillus itself. Mixed infection 
is common. 

Tetanus — symptomatology : Incubation varies from one to 
twenty-two days, usually one to two weeks. The symptoms 
of tetanus are due chiefly to a poison (toxin) produced by the 



TETAXUS. 



119 



tetanus bacillus. From what lias been said about the etiology 
it is not strange that the wounds through which the tetanus 
bacillus gains entrance to the body are usually situated on 
those parts of the body which come most frequently in con- 
tact with the earth — the feet and hands. 

The patient ustially first complains of stiffness of the mus- 
cles of the neck and jaw. Sometimes the first symptom is a 
spasm of the muscles near the point of inoculation. AVith the 
spasm there is pain. The stiffness of the muscles of the neck 
and jaw extends so as to prevent opening the mouth {trismus, 
lochjaw): and to catise retraction of the head, sometimes com- 
plete opisthotonos, arching of the body backward ; rarely 
einprosthotonos. arching of the body forward ; or pleurothoto- 
nos, arching of the body to one side. The spasms are con- 
stant, except during sleep or narcosis (chloral, opium, and 
chloroform). 

There is difficulty in sicallovnng. Affection of the muscles 
of the face causes the sardonic grin, risus snrdonicus, de- 
scribed by Hippocrates. There may not he fever. There is 
free perspiration. There may be diffculty of breathing and 
cyanosis. 

Diagnosis : Stiffness of the muscles of the neck and jaw, 
especially following trauma with liability of infection with 
the tetanus hacillas. shotild lead to suspicion of tetanus. 

The differential diagnosis concerns strychnine-poisoning, 
which shows no period of inctibation, and in which the 
muscles of the extremities are most frequently affected ; and 
hydrophobia, in which there is early ditficulty in respiration, 
from attempts to swallow. 

Tetanus — prognosis : Always grave. Rarely cases may 
show only stiffness of the muscles of the neck and jaw, but 
the diagnosis of such cases is doubtful. In severe cases 
death may occur within two or three days. As a rule death 
takes place in eight to twelve days, or recovery in three to 
six weeks. Death usually occurs through spasm of the mus- 
cles of respiration or throusch heart-failure. 

Tetanus — prophylaxis : Infected wounds should be treated 
antiseptically. Xails or splinters removed from wounds 
should be examined for the bacillus tetani ; and if this is 



120 



INFECTIONS. 



found, excision of the infiltrated area or the amputation of 
a member may be considered. 

In cases in which the spasm first appears in the muscles 
near the point of inoculation, resection of the nerve leading 
to the area of the wound has in some cases appeared to pre- 
vent the development of the disease. 

Tetanus — treatment : Most is promised by the antitoxin 
treatment. The subcutaneous use of the tetanus antitoxin 
has given a mortality of 50 per cent, or less. Better results 
have been secured by the intracerebral injection of the anti- 
toxin. 

It is believed that the tetanus toxin reaches the brain and 
cord through the nerves and blood. Knorr made an emul- 
sion of the cerebrum of a guinea-pig, to which he added 
tetanus toxin. The mixture was then centrifugalized. Thus 
there was secured a precipitate, consisting of the cerebral 
matter, evidently in intimate association with the toxin, since 
the upper layer of fluid was found to contain none of the 
toxin. 

When the tetanus toxin is injected into the brain-substance 
the union between the poison and the cerebral matter is so 
prompt that the action of the toxin may be limited to certain 
groups of cells (Roux and Borrel). Different symptoms are 
produced by the injection of the toxin into various parts of 
the brain. Animals, whose blood shows the presence of the 
antitoxin of tetanus, may succumb to intracranial injections 
of the toxin. Antitetanic serum is much more effective when 
injected into the brain than when used subcutaneously. 

The antitoxin is of little value in treatment after the de- 
velopment of symptoms. Such treatment is better in subacute 
than acute cases. In all cases, 20 to 50 c.c. of the antitoxin 
should be given as early as possible. 

In tetanus the phagocytes not only destroy the tetanus 
bacilli, as far as they are able, but they also absorb the toxin. 
Baccelli has secured good results by the subcutaneous injec- 
tion of carbolic acid, 2 per cent, solution, beginning with grs. iij 
in the twenty-four hours and increasing to gr. vj-ix in the 
twenty-four hours. There is remarkable tolerance to carbolic 
acid in tetanus. 



HYDROPHOBIA. 



121 



General treatment : The patient should be kept quiet, and 
secluded from light and noise as well as from unnecessary 
visitors. Feeding should not be neglected. The diet should 
be light and nutritious, and if necessary may be given per 
rectum. 

Various remedies have been used, among them the bromides, 
Indian hemp, chloral, opium, chloroform, atropine, calabar 
bean, curare, and carbolic acid. 

HYDROPHOBIA (Rabies (Latin); Wuth, Hundswuth, Tollwuth 
(German); La Rage (French)). 

Definition : An acute infectious disease, communicated to 
man from the lower animals, especially the dog (" mad dog"), 
by inoculation, usually through bites, and characterized in 
man by fear of water, or rather by inability to swallow, a 
symptom that is absent in animals. 

Etiology : The disease is found in the dog, fox, wolf, cat, 
and skunk, and may be communicated to other animals or to 
man by inoculation. Hydrophobia may be communicated at 
any time in the course of the disease, even during the period 
of incubation. 

Hydrophobia — symptomatology: Incubation usually lasts 
from six weeks to two months, but is very variable. 

The premonitory stage is dominated by disturbances in the 
jjsychical sphere. There are depression and melancholia, 
headache and anorexia, insomnia and irritability, increased 
sensibility, and a feeling of impending danger. The larynx 
is injected, and there may be some difficulty in swallowing. 
The point of inoculation may show irritation, pain, or numb- 
ness. 

The stage of excitement, which lasts from a day and a half 
to three days, is marked by great hypeixesthesia, excitability, 
restlessness, and inability to swallow. Water or liquid food is 
more dreaded because it more readily suggests the act of 
swallowing. Mania, or general convulsions, may be present. 
Sometimes there is satyriasis or nymphomania. There is 
usually some fever, 100° to 103° F. 

Paralytic stage: Gradually the spasms disappear, and the 



122 



INFECTIONS. 



patient becomes quiet, and later unconscious. The heart's 
action becomes feeble, and death by syncope may occur in 
from six to eighteen hours. 

The diagnosis of hydrophobia is easy in the presence of 
typical symptoms, especially spasm of the muscles of degluti- 
tion and respiration, and the history of exposure to infection, 
most commonly a dog-bite. 

The differential diagnosis concerns especially lyssophobia, 
hysteria, Landry's paralysis, tetanus, and uraemia. 

Prognosis : Bad. Recoveries from hydrophobia have been 
claimed; but with our present knowledge, the positive demon- 
stration of the disease would be difficult in cases that recover. 
Dogs hav^e recovered from rabies. Much is claimed for the 
treatment recommended by Pasteur. 

Hydrophobia — prophylaxis : Rabid animals should be killed 
and all dogs should be muzzled or confined. 

Bites of animals, especially of those suffering from rabies, 
should be thoroughly cauterized and kept open. Keirle gives 
a mortality of 30 per cent, following cauterization, against 80 
per cent, in cases that were not cauterized. Where cauteriza- 
tion may not be resorted to at once, it may be advantageous to 
ligate above the wound ; to suck the wound or apply cups, 
or open up the wound, or even to resort to amputation. In 
all cases it is best to make free use of antisepsis. 

Where practicable, the individual should receive the 
prophylactic inoculations recommended by Pasteur. 

Pasteur found the virus of hydrophobia located in the central 
nervous system, especially the spinal cord. Inoculation from 
rabbit to rabbit increased the virulence and decreased the 
period of incubation. The virus used as a standard will 
cause the symptoms of hydrophobia after an incubation of 
seven days. The virus is attenuated by desiccating the spinal 
cords in sterilized glass jars containing caustic potash. After 
two weeks' desiccation, the spinal cord is perfectly innocuous. 
Beginning with the injection of an emulsion of such a non- 
virulent Cord, successive injections are made of the emulsions 
of more virulent cords — that is, cords that have not been des- 
iccated so long — until the individual is able to receive an in- 
jection of the emulsion of a cord that has been desiccated 



DENGUE. 



123 



only five days. At this point the greatest protection is se- 
cured. 

Hydrophobia — treatment : The patient should be kept in a 
darkened room and visitors excluded. The spasms may be 
allayed by inhalations of chloroform and the use of morphine 
hypodermatically. The patient should be fed. Liquid food 
may sometimes be given after the throat is cocainized. If 
necessary, food may be given per rectum. 

DENGUE (Break-bone Fever). 

Definition : An acute infectious disease of short duration, 
characterized by severe pains in the head, eyeballs, and joints; 
inflammation of exposed mucous surfaces, swollen salivary 
glands, and a peculiar eruption. The disease often occurs in 
epidemic form, and is in some places endemic, as in Calcutta. 

The etiology is not clear. McLaughlin (1886) claimed to 
find micrococci in the blood in cases of dengue, but the ob- 
sers^ation lacks confirmation. 

Dengue — symptomatology: Incubation, two to five days. 
The onset is sudden, with chilly sensations, headache, con- 
gested conjunctivae, and pains in the eyeballs, muscles, and 
joints. The mucous membranes exposed to the air become 
inflamed. There are sore throat and swelling of the submax- 
illary glands. The fever rises gradually to 103° to 107° F.; 
pulse 100 to 120; respiration hurried. A scarlatiniform rash 
appears within one or two days, usually first upon the face, 
sometimes on the chest, back, abdomen, and knees, and lasts 
about a day. From three to four days later the terminal rash 
appears, usually first on the palms of the hands, sometimes 
followed by desquamation. This rash may be so slight as to be 
scarcely observed, or so severe as to cause ecchymoses. There 
may be some fever. Convalescence is tedious. The severity 
of individual symptoms varies in diflFerent epidemics, as well 
as in difi^erent cases. 

Diagnosis : At first dengue may resemble scarlatina or rheu- 
matism, but later the differentiation is easy. The resemblance 
between dengue and mild cases of yellow fever is more 
marked. Suspicious cases should be isolated until the differ- 



124 



INFECTIONS. 



entiation is absolute. Dengue should be differentiated also 
from influenza, typhoid fever, and malaria. 

Prognosis : Adults rarely die. Death occasionally occurs 
through some complication, such as septicaemia following 
abortion. Children may suffer convulsions and death. 

Dengue — treatment : The patient should have good hygienic 
surroundings, thorough ventilation, and isolation. The intes- 
tinal canal should be cleansed, best with calomel, rhubarb, 
or colocynth ; but the use of active purgation or emesis is un- 
called for. Temperature above 105° F. calls for hydrother- 
apy, the cold bath, or cold sponging. Tincture of belladonna, 
gtt. x-xv, gives great relief. When there is pain opium may 
be given, especially to secure sleep. Opium is probably best 
given in the form of Dover's powder. 

Complications call for appropriate treatment. 

PLAGUE (Bubonic Plague ; the Pest). 

Definition : An infectious disease, due to a specific bacillus, 
characterized by swelling of the inguinal and other lymphatic 
glands (buboes), often with the appearance of carbuncles and 
hemorrhages. 

History : The disease probably existed before the beginning 
of the Christian era, but the first reliable account is of an 
epidemic in Constantinople, 542 A. d. The bacillus was dis- 
covered by Kitasato and Yersin, during an epidemic in China, 
in 1894, when the disease prevailed especially in Hongkong 
and Canton. The plague has never appeared in America. 

Etiology : The bacillus of bubonic plague, the bacillus pestis 
of Kitasato, is found in all cases of plague, and has been 
proven by inoculation of pure cultures to be the specific cause 
of the disease. Bad hygienic surroundings are supposed 
to be predisposing causes. 

Plague — symptomatology : Incubation, two to eight days. 
Usually the symptoms come on rather suddenly, with lassi- 
tude, loss of strength, mental anxiety, sometimes with head- 
ache and vertigo, pain in the back and limbs, fever, and deli- 
rium. There is an invasion of the lymphatics in two or three 
days, which ends in resolution or suppuration, sometimes 



ACUTE INFECTIOUS ICTERUS. 



125 



gangrene. Carbuncles, petechise, or purpuric spots may ap- 
pear upon ditFerent parts of the body. 

Diagnosis : Pains in the regions of the lymphatics, especially 
the inguinal, with later tenderness, swelliug of the glands, 
and the formation of buboes, with the appearance still later 
of carbuncles and hemorrhages, stamp the disease. In doubt- 
ful cases the bacillus should be isolated. 

The plague should be differeidiated from lymphadenitis 
due to other causes — tuberculosis, syphilis, typhus fever, and 
anthrax. 

Prognosis : Should be guarded. Death may occur within a 
few hours. Much depends upon the severity of the symptoms. 

Prophylaxis : Calls for proper sanitation, especially regard- 
ing sewage and water-supply. Patients shoiud be isolated 
until at least a month after recovery. The dead should be 
buried at a depth of three meters, or preferably cremated 
(Kitasatoi. The excrement and all articles that come in con- 
tact with the patient should be burned or thoroughly steril- 
ized. 

Plague — treatment : AVith the serum treatment Yersin, in 
cases treated with strong serum, had only two deaths in 
twenty-six cases. Further treatment is symptomatic. 

ACUTE INFECTIOUS ICTERUS (Acute Febrile Icterus; Weil's 

Disease . 

Definition : An acute infectious disease, characterized by 
fever, prostration, icterus, and gastro-intestinal disturbances. 
Etiology: Probably due to the bacillus proteus fluorescens 
( (Jaeger). The disease seems to show a preference for summer 
i and the male sex. 

Acute infectious icterus — symptomatology : Prodromata are 
usually absent. The onset is usually sudden, often with a 
chill. On the fourth or fifth day the fever may remit and 
recur in two or three days, lasting eight to ten davs. There 
are intense prostration and marked jaundice, mental dulness, 
I sometimes delirium and coma. The urine, diminished in 
I quantity, contains bile, and in about half the cases albumin 
and casts, sometimes blood. 



126 



INFECTIONS. 



Diagnosis : The absence of prodromata, the sudden onset, the 
remissions, and the duration of the disease are more or less 
characteristic. The disease should be differentiated from simple 
catarrhal jaundice and from typhoid fever with jaundice. 

Prognosis : Usually good. Death has occurred, but recovery 
is the rule. 

Acute infectious icterus — treatment : A milk-diet is best. 
Active purgation should be avoided. Small doses of calomel 
or castor-oil may be given early in the disease. Carlsbad 
water or the Carlsbad salt is used. Irrigation of the large 
intestine is recommended. 

MALTA FEVER (Mediterranean Fever; Rock Fever; Neapoli- 
tan Fever). 

Definition : An infectious disease of long duration, caused 
by the micrococcus melitensiSj characterized by fever, prostra- 
tion, constipation, relapses, enlargement and softening of the 
spleen, often by rheumatic or neuralgic pains, sometimes by 
swelling of the joints and orchitis. 

Etiology: The micrococcus melitensis (Bruce, 1887) has 
been proven to be the specific infectious agent, by inoculation 
of animals and by an accidental inoculation in man. The 
disease is endemic upon the island of Malta, and appears also 
in Naples and other Mediterranean ports ; is more prevalent 
during the hot months — May, June, especially July. The 
disease has appeared in the United States. 

Malta fever — symptomatology : Incubation six to thirty 
days, usually about two weeks. 

The early symptoms are malaise, anorexia, nausea, some- 
times vomiting, sleeplessness, epistaxis, coated tongue, conges- 
tion of the pharynx, as a rule constipation, sometimes diarrhoea 
from indiscretion in diet, the stools sometimes containing 
blood, with enlargement of the spleen and liver, profuse per- 
spiration, sudamina, usually a slight cough with scanty expec- 
toration and moist crepitant rales which last a week or ten 
days, sometimes a month. The symptoms clear up and the 
patient apparently enters convalescence. Sooner or later 
there is a recurrence of symptoms. There are considerable pros- 



MILIARY FEVER. 



127 



tration and marked weakness. The number of red blood- 
corpascles is diminished. Temperature 101 "-104^ F.. and 
irregular. There are pains in the joints, which show swelling ; 
intercostal neuralgia, sciatica ; and orchitis. After some 
weeks' duration the fever gradually subsides, the number of 
red blood-oorpuscles returns to the normal, the strength im- 
proves, and the weight increases. 

The symptoms may occur in all grades of severity. In 
some cases the symptoms may be sr* slight that only a rise in 
temperature will be noticed. The di-ease usually lasts about 
two or three months. 

Diagnosis : Malta fever is to be differentiated especially 
from typhoid fever, which it often simulates so closely as to 
be recognized (jnly by the clumping of the micrococcus meli- 
tensis upon the addition of the serum, should the case be 
Malta fever ; or by the paralysis and clumping of typhoid 
bacilli, in the blood-test, in cases of typhoid fever. Malaria 
may be ruled out by a search for the pla^mndium. 

Prognosis : The mortality is abotit 2 per cent. 

Malta fever — prophylaxis : If possible, the region of the 
Mediterranean should be avoided, especially during the hot 
months. Where this is not possible special attention should 
be paid to hygiene, especially with regard to sanitation and 
personal cleanliness. Fatigue and intemperance should be 
avoided. 

Malta fever — treatment : The diet, consisting largely of 
milk. eggs, beef-tea, and brandy, must be continued for -e\'eral 
weeks. Fresh lemonade or lime-juice should be added, to 
prevent scurvy. After the temperature has remained nnrmal 
two weeks the patient may return t<» ordinary diet. 

The treatment is symptomatic. High temperature calls f ^r 
the cold bath, which must be rept-ated whenever the tempera- 
ture reaches 103^ F. 

MILIAEY FEVER Sweating Fever \ 

Definition: An infectious di-ease. <-ccurrii]2' especially in 
France. Italy. Germany, and Austria, characttrized by fever^ 
profuse sweating and a miliary eruption uf vesicles. 



128 



INFECTIONS. 



History : The disease was first described in London, 1485, 
as sudor An<»liciis; TxMpsic, 1652; France, Montbeliard, 
1712, and Al)V)ovillc, 1718. 

The etiology is obscure. 

Miliary fever — symptomatology : There may or may not be 
prodroniatn, lassitude, anorexia, and headaclie. Perspiration 
is profuse and persisteut. There is great thirst; the mouth 
is (by ; the touii^ue is coated. Usually there is constipation. 
About the third day, as a rule, the miliary eruption appears, 
preceded by a pricking sensation and itching of the skin, first 
as papules, which later become vesicles. The eruption lasts 
two or three days, and the symptoms disappear within a week 
or ten days from the onset of the disease. 

The nervous phenomena are prominent : constriction or 
oppression in the epigastric region with mental anxiety ; 
palpitation ; sometimes cardialgia and constriction of the 
pharynx. ()(!casionally there are delirium, less constantly 
general malaise, fatigue, headache, pains in the joints, vertigo, 
and insomnia. 

Diagnosis : In the ])resence of an e])idemic the diagnosis is 
usually easy. Miliary fever should be diffei'entiated espe- 
cially from scarlet fever, puerperal sepsis, and measles. 

The prognosis varies greatly in different e])idemics. 

Prophylaxis calls for sanitation, isolation, disinfection. 

Treatment is symptomatic. 

BERIBERI. 

Definition: An infectious disease, occurring especially in 
tropical and subtroj)ical regions, characterized by motor pare- 
sis, beginning in the lower extremities, with oedema and 
sensory distui-bances, visceral disorders, especially of the 
heart and lungs. The disease is of long duration, and fre- 
quently shows acute exacerbations. 

Etiology : Various micro-organisms, chiefly micrococci^ have 
been described. 

Beriberi — symptomatology : The disease shows almost in- 
finite variations and combinations of symptoms. The symp- 
toms most frequently present depend ui)on paresis, atrophy, 
numbness, and oedema. There may or may not be fever. 



GLANDULAR FEVER. 



129 



The pulse varies greatly in different cases. Usually there is 
palpitation. Perspiration may be diminished or absent, or 
greatly increased. 

Diagnosis : Usually easy in regions where the disease is 
endemic. 

Beriberi should be differentiated especially from locomotor 
ataxia, progressive muscular atrophy, paralysis, myelitis, poly- 
neuritis, diseases of the heart, anaemia, malaria, and Bright's 
disease. 

Prognosis : Should be guarded. Mortality varies greatly in 
different epidemics. 

Prophylaxis : Demands isolation, proper attention to hygiene, 
especially sanitation and disinfection. 
Treatment is symptomatic. 

GLANDULAR FEVER. 

Definition : An acute infectious disease, characterized by 
adenitis and the absence of eruption. 

Etiology : The disease occurs most frequently in childhood, 
|i sometimes in infancy, rarely in age. The specific cause is 
i! unknown. 

J Glandular fever — symptomatology : Incubation, five to fifteen 
Ij days, usually six or seven days. The onset is sudden with 
malaise, nausea, sometimes vomiting. The tongue is coated. 
Temperature 101°-103° F. Constipation is the rule. The 
anterior cervical glands are most frequently affected, usually 
first on the left side. There is apparently stiffness of the 
neck, since movement causes pain. The glands show enlarge- 
ment about the second or third day, when the temperature is 
highest. Uncomplicated cases do not show suppuration. 
Usually the liver is enlarged. Enlargement of the spleen is 
found in about half the cases. The beginning of conva- 
lescence is usually marked by the passage of thin green stools 
containing mucus. The glands begin to diminish in size from 
two to five days after they begin to swell. As a rule the 
fever and symptoms continue five to ten days, sometimes as 
long as two weeks, when there is a successive involvement of 
different groups of glands. The patient is depressed and 
ansemic. Convalescence requires one or two months. 
9— P. M. 



130 



INFECTIONS. 



Diagnosis : Tonsilitis and phannigitis should be excluded. 
Glandular fever should be differentiated especially from irreg- 
ular cases of rubella and mumps. 

Prognosis : Good. Death may occur in the case of delicate 
children. 

Treatment is symptomatic. 

SIMPLE CONTINUED FEVER. 

Definition : Cases characterized by an elevation of tempera- 
ture, more or less continuous, which may not be classified 
under any of the known diseases. 

Etiology : Probably due to a number of causes. The diag- 
nosis of "simple continued fever" frequently arises from a 
failure to recognize the true nature of the disease. 

Symptom : The only characteristic is the elevation of tem- 
perature, which may last from a few days to a few months. 

Diagnosis : Other diseases should be ruled out, especially 
tuberculosis, typhoid fever, malaria, and intestinal ptomain- 
poisoning. 

Treatment symptomatic. Persistent cases call for change 
of residence. 

HAY FEVER (Autumnal Catarrh; Catarrhus -Sistivus; Rhinitis 
Hypersesthetica ; Hay Asthma ; June Cold ; Summer Catarrh.) 

The disease occurs most frequently in the fall, and is marked 
by catarrh of the upper air-passages, especially of the nose, 
with coryza, sometimes inflammation of the eyes, conjunc- 
tivitis, and lachrymation. 

Etiology : Hay fever has for a long time been ascribed to an 
irritability of the nervous system, and it has been observed 
that the attacks are apparently caused most frequently by the 
pollen of ragweed (Ambrosia artemesifolia) and golden rod 
(Solidago odora) ; more rarely by wheat, barley, oats, rye, and 
Indian corn. Dust and the odor of animals and flowers some- 
times cause the disease. The disease is probably due to some 
micro-organism that finds a favorable soil in the pollen. Often 
there is hypersesthesia of the nasal mucous membrane. 

Symptoms : Hay fever is most frequent in middle life, but 



HAY FEVER. 



131 



infancy and old age are not exempt. The disease shows a pecu- 
liar periodicitif, in that the attacks recur each year upon about 
the same day, sometimes at the same hour. There are noticed 
early tickling and irritation of the conjunctivae and of the 
mucous membrane of the upper respiratory passages, espe- 
cially of the nose. Soon there are sneezing, coryza, and 
lachrymation. There may be two or three degrees of fever 
and some increase of the pulse-rate. AVith the local symp- 
toms there is more or less malaise and prostration. Some- 
times there is jmin in the muscles, eyes, and occipital 
region. The general symptoms seem to be due to a tox- 
cemia. Sometimes early, usually after the disease has existed 
two or three years, asthmatic attacks assume prominence. 
These usually appear late in the season, but may begin 
early in the attack. The attacks usually cease after a few 
hard frosts. 

Diagnosis: The coryza, often with lachrymation, sometimes 
with asthma, comes on suddenly, about the same time on 
succeeding years. Differential diagnosis has to do chiefly 
with acute nasal catarrh, influenza, and spasmodic asthma. 

Prognosis : Hay fever is not a fatal malady. Almost all 
cases may be relieved, many may be cured, but some cases 
persistently recur year after year. 

Hay fever — treatment : A change of place of residence, 
especially to a cooler climate, will relieve many cases. Some- 
times it is only necessary to take a trip at the time of the 
expected attack. Some cases may be benefited by tonics. 

In the way of "palliative treatment most relief is afforded 
by opium and belladonna, or morphine and atropine, but these 
remedies should not be used indiscriminately as a routine treat- 
ment. The local application of cocaine may give great but 
only temporary relief. Nasal spurs or adenoids should be 
removed, which is sometimes followed by a cure of the hay 
fever. Sensitive areas, which are most frequently found upon 
the nasal septum, may sometimes be cured by cauterization, 
after which the hay fever may disappear. 

Probably the best single remedy is arsenic, Fowler's solu- 
tion, gtt. ij-v three times a day up to tolerance. Quinine may 
be given, gr. v, morning and evening. A boracic acid oint- 



132 



INFECTIONS. 



ment in vaseline, 5 per cent., is useful. Conjunctivitis is 
relieved by the instillation of cocaine, 4 per cent, solution, or 
morphine, 1-2 percent, solution. Chlorate of potassium may be 
given internally, a teaspoonful of the saturated solution every 
two hours. The asthma is sometimes relieved by chloral, 
gr. V, or the iodides. Headache and fever are relieved by 
phenacetin and the salicylates. 

ACTINOMYCOSIS (Big Jaw; Swelled Head ; Holzzunge, Knochen- 
krebs, Kinnebeule (German)). 

Definition : A disease, found especially in cattle, sometimes 
in man, caused by the ray fungus, adinomyces. 

Etiology : In the pus or granulations the fungus appears as 
whitish, more often yellowish, granules, which under the 
microscope are seen to consist of threads radiating from a 
centre and ending in club-shaped extremities. Bostroem 
would classify the parasite among the polymorphous bacteria, 
since the masses contain cocci and bacilli, some of which are 
branched and show club-shaped extremities (Ponfick) (see 
Tuberculosis). 

The organism has been cultivated outside of the body, and 
inoculation-experiments upon animals have been successful. 

The disease may occur in man by direct transmission from 
infected animals or from foreign bodies, especially cereal 
grains with sharp extremities, more rarely isinglass, splinters, 
etc., which may contain growths of the parasite. Infection 
may occur through carious teeth, and Ponfick has reported 
infection from barbers' utensils. 

In maUj actinomycosis is found most frequently in the head 
(jaw, tongue), neck, air- passages (lungs), alimentary canal 
(small intestine), and skin. 

Actinomycosis — symptomatology: The infection runs a 
chronic course. The symptoms, at first ol^scure, increase 
insidiously, and show variations according to the location of 
the actinomycotic process. As a rule, wherever the process 
develops there is the formation of granulation- tissue, abscesses, 
and fistulce. The infiltration is peculiar, and has been de- 
scribed by Ponfick as tough.'' Bones, when attacked, are 



ACTINOMYCOSIS. 



133 



expanded and eroded. Affection of the lungs may cause 
cough, expectoration, irregular fever, emaciation, night-sweats, 
and the formation of cavities closely resembling pulmonary 
tuberculosis, and life may be terminated by tuberculosis or 
amyloid degeneration. 

In the intestine the process is slow, permitting protection 
of the general peritoneal cavity by the adhesion of coils of 
intestine. Frequently the first suspicion of the disease may 
be afforded and verified l)y the discharge of the jpecidiar 
granular pus containing the parasite, from a sinus which 
may be in the lumbar, more rarely in the gluteal or perineal, 
region ; sometimes in some other part of the abdominal 
wall, coQimunicating with the intestine or bladder. 

Diagnosis, to be absolute, depends upon the detection of 
the parasite, ray fungus, which not infrequently is to be 
found in granular pus discharged from a sinus ; sometimes 
in the sputum, in cases of involvement of the air-passages 
(lung). Suspicion may be aroused by the insidious onset and 
chronic course of the infection, the presence of granulation- 
tissue, fistulce, and abscesses. 

Karlowski gives, as a point in differential diagnosis, that 
dulness is found below the clavicle in actinomycosis of the 
lungs, and not at the apex of the lung as in tuberculosis. 

Prognosis : Depends upon the location of the process, 
especially upon the accessibility of the infectious foci to sur- 
gical treatment. 

Prophylaxis : Care should be taken of the teeth and mouth. 
Animals should receive good food, not containing thorns. 
The parasite should be destroyed, best by fire. 

Actinomycosis — treatment : Wherever })ossible the deposits 
of the fungus should be thoroughly removed or destroyed 
with the knife or cautery. AVhere this is not practicable, 
Ponfick advises repeated injections of bichloride of mercury, 
1 : 500. Further treatment is symptomatic. 

Karlow^ski successfully treated a case of pulmonary actino- 
mycosis by incision, resection of a rib, the use of the 
Paquelin thermo-cautery, and the application of iodoform- 
gauze. The internal use of iodide of potassium has been 
recommended in visceral affection, but was found ineffectual 



134 



INFECTIONS. 



by Poncet in 18 out of 25 cases. The remedy is useful only 
in the earliest stages. 

DISEASES CAUSED BY ANIMAL PARASITES. 

MALARIA ( Intermittent Fever ; Chills and Fever ; Ague ; Swamp 
Fever; Marsh Fever; Miasmatic Fever; Wechselfieber (Ger- 
man)). 

Etymology : Malaria^ from mal'aria (Italian), meaning bad 
air. It has been suggested that mal aqua would be a better 
name for the disease. 

Definition : An infectious disease, acute or chronic, caused 
by the hsematozoon (plasmodium) malarise ; appearing some- 
times as a pernicious fever ; usually as a fever of intermittent 
or remittent type ; frequently as a chronic cachexia with 
anaemia and enlargement of the spleen. 

History : Malaria was known in the remotest antiquity. 
The disease was described by Hippocrates. Celsus and Galen 
recognized the quotidian, tertian, and quartan types. Perni- 
cious paroxysms were described by Mercatus, toward the end 
of the sixteenth century. Cinchona bark was introduced into 
Europe, in the treatment of malaria, by the Countess del 
Cinclion and her body-physician, Juan del Vega, 1640. 
The malarial parasite was discovered by Laveran in Novem- 
ber, 1880. Golgi described some of the varieties of the para- 
site found in quartan and tertian types of the disease, 1885-6. 
Marchiafava and Celli described varieties of the parasite in 
sestivo-autumnal fever, 1889. 

Etiology : The specific cause of malaria is now generally 
recognized to be the malarial parasite, the oseillaria malarice 
of Laveran, more commonly known as the plasmodium mala- 
r'm (Marchiafava and Celli), more properly the hcematozodn, 
or better the hceynocytozoon malarice. The term hmnospoiddium 
has been recommended, but not generally adopted. 

The malarial parasite belongs to the protozoa, a class of 
unicellular animals, and to the group hcemocytozoa, since it 
develops within a red blood-corpuscle. There is a difference 
of opinion as to whether the different forms of malaria 
(tertian, quartan, and autumnal) are due to the same organism 



MALABIA. 



135 



or to different varieties of the malarial parasite. It is known 
that certain appearances of the parasite are peculiar to the 
different forms of malaria. 



Fig. 15. 




Plasmodium malarise of a febris tertiana in various developmental stages (after 
Golgi). o, first step in development; 6, c, enlarged Plasmodia ^vitll pseudopods ; 
d, Plasmodia before the formation of spores— blood-corpuscle decolorized ; e, for- 
mation of spores ; /, free parasite with flagella. 

In the tertian form of malaria the parasite (Fig. 15) appears 
first as a small hyaline amceboid body, becomes pigmented with 
granules in active motion, and grows to about the size of a 



Fig. 16. 




Plasmodium malarise of a febris quartana in various stages of development (after 
Golgi). a, red blood-corpuscle -with a small, non-pigmented Plasmodium: b, c, 
d, e. pigmented, variously sized Plasmodia inside "of red blood-corpuscles : /, 
Plasmodium at the commencement of segmentation, with pigment collected in 
centre: q. segmented Plasmodium: h. Plasmodium divided into separate glob- 
ules; i, J:, two differently shaped, free Plasmodia, 

red blood-corpuscle. The corpuscle becomes expanded and 
decolorized. The parasite then breaks up into fifteen or 
twenty segments (spores). 



136 



INFECTIONS. 



In the quartan fever (Fig. 16) the amoeboid movements 
are slower than in the tertian form, and the granules of pig- 
ment are coarser and present less active motion. The cor- 
puscle contracts around the parasite and shows a somewhat 



Fig. 17. 




d e 

Plasmodium malarise of a febris quotidiana in various stages of development (after 
Celli and Sanfelice). a, first step in the development; 6, Plasmodium with 
pseudopods : c, Plasmodium which has become round and provided with pig- 
ment before segmentation ; d, formation of spores ; e, intraglobular crescent 
form ; /, g, free Plasmodia. 

deeper color. The parasite breaks up into only five or ten 
segments, arranged in the form of rosettes around a central 
clump of pigment. 

The cestivG-autumnal parasite is still smaller, reaching only 
half the size of a red blood-corpuscle, and presents less pig- 

FiG. 18. 



























































































































f 












1 




















^ 


















































































































































t 
























\J 














V 









































































































Temperature-curve in man after injection of blood from patient affected with mala- 
rial (quartan) fever. X 12, noon, injection of four cubic centimetres of blood : 
+ injection of two grammes of muriate of quinine (Baccelli). 

ment. The corpuscles become contracted around the parasite, 
often crenated. After about a week the characteristic cres- 
centic, ovoid, and round bodies ap}>ear, containing central 
clumps of coarse pigment-granules. The round bodies of this 



MALARIA. 



137 



form of the parasite, as well as the full-grown tertian and 
quartan parasites, may present flagelli, which show active 
movement and may become detached from the corpuscles and 
appear free in the blood. 

MacCallum has shown that the flagelli are the male elements 
of reproduction. 

Malaria has been transmitted by subcutaneous inoculation 
with blood, the disease appearing in the same form as in the 
case from which the inoculation was made. It is supposed 
that infection may also gain entrance to the body through the 
respiratory tract, but this has not been proven. 

Nothing is known of the life-history of the parasite outside 
of the body. Attempts at cultivation upon artificial media 
have been unsuccessful. 
] A peculiarity of malaria is that it may prevail in a region 

for an indefinite length of time and suddenly disappear, seem- 
ingly without cause, to reappear at some future time. The 
disease seems to prefer a low, swampy country and to avoid 
altitude. Often the occupants of the ground floor of dwell- 
ings may be attacked, while those in the upper stories escape. 

An exception to the rule seems to be found in Quetta, India, 
which is almost 6000 feet above the level of the sea, and upon 
which some hills reach 12,000 feet above sea-level. Quetta 
is affected periodically by malaria, especially during Septem- 
ber and October (Birch). 

The mosquito plays a prominent role in carrying the infec- 
tion, producing the disease in man by direct inoculation. 

Grassi believes the species of mosquito that acts most fre- 
quently as purveyors of malaria are the following : anopheles 
clavif/es (Fabr), culex penicillaris (Roudani), and culex horten- 
sis (Ficalbi). 

Malaria — symptomatology : The period of incubation is not 
accurately known, but probably varies from one to two weeks. 
In cases where malaria has been produced experimentally the 
incubation has lasted in the quartan type from eleven to fif- 
teen days ; in the tertain type, six to twelve days ; and in the 
cestivo-autumnal type, two to five days. 

The vegulsiY intermittent types, tertian and quartan, are char- 
acterized by regularly recurring paroxysms of chill followed 



INFECTIONS. 
Fig. 19. 




Tertian fever (Seguin). 



hy fever, later sweating. The paroxysms are often preceded 
by uneasy sensations, especially in the epigastrium, and some- 



FiG. 20. 




RESP. | 24| |30 | |20| 120 



Quotidian fever (Seguin). 



times by headache. With the onset of the jja^'oxysm there 
are lassitude, headache, sometimes nausea and vomiting, a 



MALARIA. 



139 



slight rise in temperature^ and a pronounced chill, the skin 
becoming cold and blue. The temperature rises, and may 
reach 105° or 106° F. The pulse is rapid, hard, and non- 
compressible. There is headache. The chill may last from 



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ten minutes to an hour or longer. Gradually the tempera- 
ture of the surface changes from cold to hot, the face is 
flushed, and the skin reddened. There may be throbbing 
headache. There is intense thirst. The hot stage lasts from 



140 



INFECTIONS. 



thirty minutes to three or four hours. Gradually sweating 
appears, the temperature falls, the headache is relieved, and 
soon the paroxysm is over. The paroxysm usually lasts ten to 
twelve hours. Between paroxysms the individual is apparently 
well. In the tertian type the paroxysms recur every third 
day — that is, about forty-eight hours apart. An infection 
with two sets of tertian parasites may cause daily paroxysms — 
the quotidian fever. In the quartan type the interval is about 
seventy-two hours, the paroxysms occurring every fourth day. 
A double quartan infection may cause paroxysms on two suc- 
cessive days, followed by an intermission of one day. A 
triple quartan infedion may cause daily paroxysms — a quo- 
tidian fever. The disease may disappear spontaneously in ten 
days or two weeks ; but recurrence is frequent. Or the dis- 
ease may become chronic, to cause malarial cachexia. 

The symptoms of cestivo-autumnal fever are more irregular, 
the paroxysms usually lasting about twenty hours. Often the 
onset is without chill, sometimes even without chilly sensa- 
tions. Frequently the temperature rises and falls slowly, 
instead of abruptly. Sometimes the fever is more or less 
continuous, running about 102° to 103° F. During the par- 
oxysms the temperature reaches 105°, sometimes 106° F. 
Frequently there is jaundice. 

Pernicious malaria may occur in the comatose, algid, con- 
vulsive, or hemorrhagic form. 

Malaria — diagnosis : Usually the regular recurrence of chill, 
fever J and sweating, with enlargement of the spleen, is sufficient 
to enable the physician to make a correct diagnosis. Doubt- 
ful cases call for microscopic examination of the blood for the 
parasite; or the administration of quinine, methylene-blue, 
or arsenic, as a therapeutic test. 

Prognosis : Usually the tertian and quartan types have a 
good prognosis, as have also cases of sestivo-autumnal fever 
that come under treatment early. The prognosis is not so 
good in cases showing the symptoms of pernicious malaria, 
especially when the paroxysms continue forty-eight hours 
after beginning treatment. 

Prophylaxis : In regions where malaria is prevalent the 
sleeping-apartments should be as far above ground as possible, 



MALARIA. 



141 



and the individual should be protected from the mosquito. It 
has been suggested that the drinking-water should be boiled. 
Quinine^ in small doses, two or three grains three times a day, 
alfbrds protection. The inhabitants of non-malarial regions 
should visit malarial districts only when the disease is least 
prevalent. 

Malaria — treatment: Quinine for malaria is one of the few 
specifics in medicine. The remedy is best given in round 
doses just before an expected paroxysm. Gr. xx-xl daily 
may be continued for three days, then smaller doses given for 
two or three weeks. Severe cases may call for the adminis- 
tration of quinine hypodermatically or by intravenous injec- 
tion. 

The following are the salts of quinine usually employed, 
with their percentage of quinine and solubility in water : 

Salts of Quinine classified according to the Percentage of the Alka- 



loid which they contain. 

Quinine. 

100 parts of the basic muriate of quinine contain 81.71 per cent. 

neutral " ..... 81.61 " 

basic lactate " 78.26 " 

" " hjdrobromate " " 76.60 " 

" sulphate " " 74.31 " 

" sulphovinate " ' ..... 72.16 " 

" " neutral lactate " " 62.30 " 

" hvdrobromate " ^' 60.67 " 

" " sulphate " 59.12 " 

" sulphovinate " " 56.25 " 

Salts of Quinine classified according to their Solubility in Water 
(Regnauld and Villejean ). 

Water. 

1 part of the neutral hydrochlorate of quinine is soluble iu .... 0.96 

" " sulphovinate " " " .... 0.70 

lactate " " .... 2. 

" basic sulphovinate at. ... 8.30 

" ■' neutral hvdrobromate " .... 6.33 

" " sulphate '< " .... 9.00 

" " basic lactate '• .... 10.29 

" '■ " hydrochlorate " " .... 21.40 

" " " hvdrobromate " " " .... 45.02 

" " " sulphate " .... 581.00 



142 



INFECTIONS. 



The salt that contains most quinine and is soluble is supe- 
rior. Therefore, quinince hydrochloras is best. 

The sulphate of quinine, which is the salt generally used, 
is much more soluble in an acid medium, and should, there- 
fore, be prescribed with an acid. 

Before quinine came into use cinchona bark was employed. 
Other derivatives of cinchona, besides quinine, have been 
recommended : cinchonin, cinchonidin, quinidin, and quin- 
oidin. 

Methelyne-blue occupies a position next to quinine in the 
treatment of malaria, and in some cases is preferable to qui- 
nine. 

Chronic cases of malaria may be treated with arsenic, best 
in the form of Fowler's solution. 

If the patient resides in a malarial district, he should seek 
more healthy surroundings. A change of residence is espe- 
cially important in advanced malarial cachexia. 

DYSENTERY (Flux; Euhr (German)). 

Definition : An infection, chiefly of the large intestine, char- 
acterized by diarrhoea with tormina and tenesmus. 

Etiology : Dysentery is most prevalent in tropical and sub- 
tropical countries, although during warm weather it may 
assume an epidemic form in temperate regions. The amaba 
coli is generally recognized as the specific infectious agent 
in many cases of tropical dysentery. But this organism is 
not always found in dysentery. Maggiori (1893) found 
amoeba in only one case in twenty. In the remaining nine- 
teen cases the bacteriological examination revealed the bacillus 
coli communis in large numbers ; the proteus vulgaris in most 
cases; and in some cases the bacillus fluorescens liquefaciens, 
the staphylococcus pyogenes aureus, staphylococcus pyogenes 
albus, and the bacillus pyocyaneus. Arnaud (1894), from a 
study of sixty cases of tropical dysentery, comes to the con- 
clusion that the disease is due largely to a pathogenic variety 
of the bacillus coli communis. Rectal inoculation with cult- 
ures of the colon bacillus produced dysentery in dogs. 

It is generally believed that dysentery is disseminated 



DYSENTERY. 



143 



largely througli the medium of impure drinking-water, con- 
taminated by faecal matter. 

Dysentery — symptomatology : The symptoms vary in 
severity. Preceding the attack tiiere may or may not be 
diarrhoea. Sooner or later the attack comes on, abrupt or 
gradual in onset, usually with pains in the abdomen and 
diarrhoea, sometimes with nausea and vomiting. The colic 
becomes violent, constituting actual tormina, and the desire to 
go to stool — tenesmus — becomes intense and more or less con- 
stant. Blood and mucus may be absent from the stools at 
first, but are usually present later on. There is ancemia. 
The disease affects chiefly the large intestine. 

The stools are characteristic. At first there is the discharge 
of the normal contents of the intestine. There may then be 
discharged large, dark-brown, thin, offensive stools, in so- 
called bilious dysentery. The stools may contain scybalce, hard 
fiecal casts of the sacculi of the large intestine. The size of 
the stools may gradually diminish until there is no passage 
even upon extreme effort, dysenteria sicca. There may be 
the discharge only of mucus, sometimes with pus, dysenteria 
alba; or blood, dysenteria rubra. There may be in the stools 
inspissated masses of mucus, pus, blood, and debris, resem- 
bling flesh in gross appearance, lotura carnea. Sometimes the 
sediment contains particles resembling sago-grains. 

Dysentery — complications : Septicaemia, anaemia, peritonitis, 
perforation, intussusception (rare), hepatic and hepato-pul- 
monary abscess, pneumonia, pleuritis, pericarditis, tubercu- 
losis, scurvy, malaria, typhoid fever, typhus fever, arthro- 
pathies, and paralyses. 

Sequelae : Prolapsus ani, fistula, hemorrhoids ; indigestion, 
irritability of the bowels, constipation ; intestinal hemorrhage, 
ulceration, gangrene, and stricture. 

Dysentery- — diagnosis : The catarrhal form of dysentery is 
characterized by frequent stools, containing blood and mucus; 
tormina and tenesmus. This form should be differentiated 
from luetic and chancroidal ulceration of the rectum^ cancer, 
stricture, the presence of foreign bodies, and intussusception. 

The acute diphtheritic form of dysentery is marked by a 
rapid and intense onset, with severe general symptoms resem- 



144 



INFECTIONS. 



bling those of typhoid fever. The differentiation from 
typhoid fever may be made by the higher temperature and 
more severe intestinal symptoms, the stools early containing 
blood and mucus and later sloughs. The spleen is not en- 
larged and there are no rose-colored lenticular spots. In the 
absence of a previous attack of typhoid fever the Widal test 
will be negative. The diazo-reaction is negative. 

The amoebic form of dysentery shows the amoeba dysen- 
terica in the stools on microscopic examination. The symp- 
toms vary greatly, and not infrequently cases are recognized 
only after abscess of the liver or lung. 

The chronic or secondary form of dysentery may not show 
characteristic symptoms of dysentery. Extensive colitis and 
ulceration may show only slight diarrhoea. The diagnosi;* 
may be made by the use of the rectal speculum and careful 
physical examination. 

Prognosis : The mortality of dysentery is high in the diph- 
theritic form ; low in the catarrhal form. In the individual 
case the prognosis depends largely on the severity of the 
symptoms. Complications increase the mortality. Recovery 
is usually slow. 

Prophylaxis : The drinking-water should be pure — at any 
rate not polluted by excrement. If necessary to drink con- 
taminated water, it should be boiled. The fsecal discharges 
of dysenteric patients should be destroyed, best by fire. 

Dysentery — treatment : Usually recovery occurs spontane- 
ously in about ten days to two weeks. The patient should 
observe absolute rest in bed. Ipecac is recommended, in 
small doses, gr. j-iij, repeated every two or three hours; or 
large doses, gr. xx-xl every four to twelve hours. Opium, 
internally or in suppositories, is useful in the relief of symp- 
toms. Castor oil, calomel, rhubarb, or the salines, sodium 
sulphate or magnesium sulphate, may be used to secure purga- 
tion. Among the antiseptics, bichloride of mercury, bismuth, 
creosote, carbolic acid, salol, naphthalin, resorcin, creolin, and 
tricresol have been used internally. Antisepsis per rectum 
is more practicable. The colon may be thoroughly irrigated 
with water, warm or cold, simple or medicated, best injected 
through the rectal tube with the patient in the knee-elbow 



TAPEWORiMS. 



145 



posture. The best results may usually be obtained by rectal 
irrigation with water containing some astringent, such as alum 
or nitrate of silver. 

Meat is the best diet, especially in the amoebic form of 
dysentery. Prostration calls for the use of stimulants. Some 
cases may be cured only by a voyage or a change of climate. 

TAPEWORMS; T^NI^; CESTODES. 

A tapeworm (Fig. 22) consists of a head (scolex), neck, and 
a body (strobilla) made up of segments (proglottides). The 
parasites are hermaphroditic. The life-history of a tapcAvorm 
(after the ovum) is divided into two periods : (a) larval or 
embryonic stage (hydatid, measles, cysticerci), and (b) the 
mature stage. The two stages are usually spent with different 
hosts. The ovum (oncosphsera) after entering the alimentary 
canal, through contaminated food or drink, finds its w^ay into 
the tissues of the body, through the bloodvessels or lymphat- 
ics, to develop into a hydatid (larval stage). When measles, 
or cysticerci (larval stage), are ingested, they develop into 
tapeworms in the intestine. 

Etiology : Tapeworms appear in man chiefly as a result of 
the ingestion of infected food, especially meat that has not 
been thoroughly cooked. The disease occurs most frequently 
in early adult life ; but age and infancy are not exempt. A 
case of infection by the t^nia armata has been reported in an 
infant ten weeks old, by Meusiuga (Dock). In that case the 
infection was carried by contaminated milk. 

Tapeworm — symptomatology : The nunibei' of symptoms 
attributed to tapeworm is legion, many of which are doubtless 
due to helminthophobia. The most important symptom is 
the passage of segments, either with the stool or, more rarely, 
by emesis. Among the more common symptoms may be 
mentioned disturbances of digestion, nausea, vomiting, and 
eructations. The appetite may be increased, diminished, or 
capricious. Abdominal symptoms are sometimes complained 
of, especially after eating certain foods, such as raspberries or 
strawberries, or foods characterized by a sour or bitter taste, 
and may be relieved by the ingestion of certain other foods, 
]0— p. M. 



146 



INFECTIONS. 





wm 



Fig. 22. especially milk. Nervous dis- 

turbances are especially common 
in children. Sometimes there is 
anaemia, which may be severe. 
There may be fever. 

Peifer believes it probable that 
the animal parasites contain or 
excrete toxic materials, which act 
as poisons, especially upon the 
nervous system and on the for- 
mation of blood. 

Diagnosis : A positive diagnosis 
can be made only upon the dis- 
covery of segments or eggs. The 
determination of the variety of 
tapeworm present in a given case 
will depend upon an examination 
of the segments or eggs. 

The prognosis is usually good 
under proper treatment. In cases 
of infection by the tcenia armata 
there is danger of cysticercus. 
Angemia is especially likely to 
be severe and possibly fatal in 
cases of infection by the bothrio- 
cephalus kit us. 

Tapeworm — prophylaxis : Ani- 
mals intended for food should 
not be fed upon excrement or 
the offal of slaughter-houses. 
Meat should be inspected before 
it is oflPered for sale, and thor- 
oughly cooked before it is eaten. 
It is well to remember, in this 
connection, that the outside of a 
piece of meat may be burned 
while the inside remains at a 
temperature that will not destroy "measles." 

Infected individuals should be warned of the danger of 






Sections from fccnia snqinnta—natn 
ral size (Leuckart). 



TAPEWORMS. 



147 



communicating the disease ; they should be cleanly. The 
hands may become contaminated, and should be thoroughly 
cleaned before they are permitted to come in contact with the 



Fig. 23. 




Proglottides of (a) tsenia saginata (6) t. solium (Leuckart), and (c) bothriocephalus 
latus (Eichhorst) ; natural size and enlarged three times to show arrangement 
of uterus. 

mouth or with food or cooking-utensils. This advice applies 
not only to patients, but to physicians as well. 

Tapeworm — treatment : For a day or two the individual 
should fast, or live only upon articles that will afford the 



Fig. 24. 




a b c 



Eggs of (a) t. saginata; (6) t. solium; (c) bothriocephalus latus; X 300 (Eichhorst). 

worm little nourishment and at the same time appease the 
patient's appetite : black coffee, pickles, cabbage, raspberry 
jam, wine, and water. A purgative, such as calomel, may be 



148 



INFECTIONS. 



administered in the evening ; and next morning, the patient 
fasting, a tseniacide may be administered, sometimes best with 
a cup of black coffee, and the patient instructed to remain in 
bed. 

Among the i^emedies in common use as taeniacides are the 
ethereal extract or oleoresin of male fern ; the rind of the 
fresh pomegranate root in powder or decoction ; or, better, the 
tannate of pelletierin. Turpentine and pumpkin-seed are 
used. 

If the worm does not pass within an hour, a purgative 
should be administered ; best a Seidlitz powder or a glass of 
Hunyadi water. If nothing passes within another hour, the 
patient should receive an enema. 

Among other tseniacides are cusso, which should not be 
given in pregnancy ; kamala, used in the form of the powder, 
4-8 grammes, or the saturated tincture, 4-12 grammes, given 
in cinnamon-water ; cocoanut, an entire nut, including the 
milk, to be used within a few hours and followed by free 
catharsis ; black oxide of copper, naphthalin, thymol and 
myrtol, salicylic acid and salol, and papain. 

Upon the expulsion of a tapeworm a search should be made 
for the head, since if the head remain alive in the alimentary 
canal the worm may continue to grow. Under such circum- 
stances segments will again appear in the faeces in the course 
of a few months. 

The following varieties of tapeworm may be noted : 

Taenia Echinococcus. 

Synonyms : Dog tapeworm ; tsenia nana of van Beneden 
[not the taenia nana of v. Siebold). 

Description : The taenia echinococcus (Fig. 25) consists of 
three or four sections, with a total length of 5.5-9.0 mm. 
(DeflPhe). The last section or proglottid is mature, about 
2.0 mm. long and 0.6 mm. in breadth, and contains about 500 
eggs (30 or 40 booklets). 

Occurrence : The parasite is found especially in the larger 
varieties of the dog, in the upper half of the small intestine, 
except ten or fifteen centimetres next the stomach. 



T^NIA ECHINOCOCCUS. 



149 



Fig. 25. 



Taenia echinococcus — etiology : The parasite exists in man 
both in the larval stage, as hydatid cysts, and in the mature 
stage, as a "tapeworm." The disease is most frequent in 
Iceland, and many cases are reported from 
Australia. In America the disease is not 
common, and many of the recorded cases 
were imported. Infection occurs largely 
through unclean habits. The eggs from the 
ripe proglottides gain entrance to the ali- 
mentary canal of man chiefly through food 
or drink contaminated by the faeces of the 
dog. 

Hydatid cysts, the larval stage of the 
echinococcus, may aifect almost any part 
of the body, most frequently the liver, 
next in frequency the lungs ; less often the 
peritoneum, which is usually afiected sec- 
ondarily ; the spleen, kidneys, muscles, 
bones, central nervous system, and the 
heart; rarely, if ever, the muscular walls 
of the stomach, intestine, or bladder, the 
uterus. Fallopian tubes, and vagina. 

Hydatid cyst — symptomatology: The 
symptoms vary with the organ afPected. 
The growth of the tumor is slow, extend- 
ing over years. As a rule pain is absent, unless caused by 
distention of some organ or by pressure on a nerve-trunk. 
Fever is absent or not characteristic. Often there is urticaria, 
especially after puncture, sometimes without evidence of 
traumatism. The hydatid thrill, fremissement hydatique, a 
peculiar vibration or crepitation, may be felt during percus- 
sion. 

Diagnosis : Suspicion may be aroused by the presence of a 
tumor of slow growth and uncertain nature, especially when 
situated in one of the organs most frequently affected by 
echinococcus, the liver or lungs. A positive diagnosis depends 
largely upon the chemical and microscopic examination. 
Otherwise the differentiation from cancer is sometimes most 
difficult. The fluid, which may be withdrawn through a fine 




Taenia echinococcus. a, 
natural size ; 6, X 12 
diameters (from Whit- 
taker and Ziegler). 



150 



INFECTIONS. 



needle, before suppuration takes place, is colorless and odor- 
less, usually of a neutral reaction, and with a specific gravity 
of 1009-1015. Chloride of sodium, which has also been 
found in other cysts, is present in large amounts, 0.61 per 
cent. (Munk) ; phosphates only present a trace. Usually the 
fluid contains sugar, sometimes uric acid. It is said that 
there is, as a rule, no albumin ; but albumin has been found 
in hydatid fluid, and is sometimes absent in the fluid obtained 
from other cysts. Succinic acid is sometimes present, and 
when found is considered characteristic. 

The microscopw examination may reveal the hooklets or 
membrane of the hydatid cyst, either of which is positive 
evidence. The hooklets have a characteristic shape, and the 
membrane is thick and has a tendency to curl at the edges. 

Prognosis : The tumor is of slow growth as a rule. The 
echinococcus may die, the cyst become sterile, undergo degen- 
eration, possibly absorption, and the patient recover. But 
such a termination should not be anticipated. 

Prophylaxis : Cleanliness should be observed that infection 
may not be received from dogs. It is not the part of wisdom 
to receive kisses from dogs after they have performed their 
customary ablutions. 

The infection of the dog may be greatly lessened by not 
feeding him upon the ofl^al of slaughter-houses, especially the 
intestines of animals that may contain echinococci. 

Hydatid cyst — treatment : The treatment is surgical. If 
possible, the cyst should be removed entire. Where this is 
not feasible, aspiration or incision and drainage may result in 
a cure. Sometimes it is necessary to amputate a member. 

Taenia Armata. 

Synonyms : Pork tapeworm ; taenia solium. The parasite 
has received the name '^pork tapeworm," because its cysti- 
cercus (larval) stage is spent most frequently in pork as the 
Gysticereus cellidoscE (measly pork). 

"Solium," according to Leuckart, is derived from a Syrian 
word meaning chain. 

Description : The tsenia armata is 2.0-3.5 m. in length. The 



T^NIA ARMATA. 



151 



head is spheroidal, 0.6-1.0 mm. in diameter, surrounded by a 
rostellum and a circle of hoolvlets, 20-32 in number. The hook- 
lets are of two sizes, 0.11-0.14 and 0.16-0.18 mm. in length, 
and alternate. The suckers are hemispheroidal, 0.4-0.5 mm. in 
diameter. The neck is 5-10 mm. long. The proglottides, of 
which there may be as many as 850, are at first greater in 
width than in length near the head, the width and length 
becoming equal about a yard from the head, while in the 
mature segments the length is about 10-12 mm. and the width 
5-6 mm. The eggs are spheroidal, 0.031-0.036 mm. in 
diameter. The uterus is a straight median canal, from which 
there are five to seven branches upon either side, given off at 
right angles. 

Occurrence: The parasite in its mature stage occurs only in 
the small intestine of man. 

In the larval stage, cysticercus cellulosse, the parasite occurs 
most frequently in the hog, as measly pork, and has also been 
found in the cat, rat, ape, and man. The cysticercus cellulosae 
is a small elliptical cyst, 6-20 mm. in length and 5-10 mm. 
in width, in which the inverted head may be seen as a wdiitish 
spot. Cysticercus infection in man has been know^n to result 
from ripe proglottides entering the stomach from the intestine 
during the act of vomiting. Cysticerci have been found in 
the brain, heart, lymphatic glands, liver, bones, tongue, eye, 
and subcutaneous cellular tissue. 

Cysticercus cellulosse — treatment : Usually the condition is 
difficult to diagnosticate during life. Cysticerci that do not 
cause severe symptoms may be let alone. The extract of male 
fern has been offered as a specific, in 1-3 gramme doses con- 
tinued for a few days. But in general the treatment is symp- 
tomatic. Cysts that can be located may be removed by the 
surgeon, where such an operation is justified by the symp- 
toms. Aspiration of the cyst is frequently resorted to, 
sometimes followed by the injection of iodine or alcohol. 
When considering the feasibility of an operation it should be 
remembered that the cysticercus may die and become calcified. 

The cysticercus acanthotrias (Weinland), a variety of the 
cysticercus cellulosse, characterized by the arrangement of the 



152 



INFECTIONS. 



hooklets in three rows, has been reported only once in the 
muscles and brain. 

Taenia Saginata. 

Synonyms : Beef tapeworm ; unarmed tapeworm. The 
name, saginata, comes from the word saginare, to fatten ; but 
the worm is not always fat. 

Description: The parasite (Fig. 22) is 4-11 m. long. The 
head is cubical, 1.5-2.0 mm. in diameter. There are four 
suckers, about 0.8 mm. in diameter, usually pigmented. The 
ripe proglottides are 16-20 mm. long and 4-7 mm. wide. The 
uterus, situated in the median line, has 20-30 or more branches. 

Occurrence : The taenia saginata occurs in the human intes- 
tine in the mature stage. Ripe segments are prone to escape 
from the anus and wander about the clothing, more so than 
the segments of the taenia armata. The eggs are oval, 
0.03-0.04 mm. long and 0.02-0.03 mm. broad. 

The cysticercus of this variety of tapeworm occurs in cattle, 
hence the name beef tapeworm. The cysticercus may be as 
large as 9.0 mm. long and 5.5 mm. wide, most frequently sit- 
uated in the internal pterygoid muscles and tongue, some- 
times in the heart, lungs, lymphatic glands, and peritoneum 
of cattle, and it has been reported found in the brain and eye 
of man. But it is doubtful whether the cysticercus of the 
taenia saginata ever occurs in man. 

Taenia Cucumerina (Bloch). 

Synonyms : Taenia canina ; taenia elliptica. 

Description : The parasite is 10-40 mm. long and 2-3 mm. 
wide. The ripe proglottides are 6-10 mm. long, in shape 
resembling a cucumber-seed. The eggs are spherical, 0.043- 
0.05 mm. in diameter. 

The parasite occurs in dogs, cats, and occasionally in human 
beings, especially in children who fondle dogs and cats. 

The cysticercus of this tapeworm lives in the dog-louse 
(trichodectes canis), dog-flea (pulex serraticeps), and human 
flea (pulex irritans). 



BOTHRIOCEPHALUS LATUS. 



153 



Taenia Nana (v. Siebold). 

Dwarf taenia : Should not be confounded with the taenia 
nana of van Beneden (see Echinocoecus). 

The taenia nana has the distinction of being the smallest 
tapeworm infecting man. Cases have been reported especially 
from Egypt, Italy, Sicily, and Germany. The parasite is 
8-27 mm. long and 0.5-0.7 mm. wide. The head is spherical/ 
0.25-0.50 mm. in diameter. There are four round suckers 
and a rostellum containing 2-4-30 booklets arranged in a 
single row. The segments are short, 150-200 in number. 
The eggs are oval, 0.04-0.05 mm. in diameter. (The eggs do 
not possess the radiating structure found in the eggs of taenia 
armata and taenia saginata.) 

There may be from 40 to 5000 of these parasites in one 
individual. 

Taenia Diminuta (Rudulphi). 

Synonyms : Taenia flavopuncta (AYeinland) ; taenia Minima 
(Grassi). 

Description: Length, 20-60 mm.; width, 3.5 mm. The 
head is club-shaped and contains four suckers and an unarmed 
rostellum. The eggs are round, 70-80 ij. in diameter. The 
parasite is common in rats and mice, and has been found in 
man, especially in children. 

The cysticercus lives in the caterpillar and in several insects 
and their larvae. 

Taenia Madagascariensis : Length, 30 cm. Armed. A few 
cases of infection by this parasite have been reported from 
the East. The immature stage is supposed to be passed in 
birds. 

Bothriocephalus Latus. 

Synonyms : Taenia lata ; broad tapeworm ; fish tapeworm. 

Description: The largest tapeworm found in man; it may 
attain a length of 9.0 m. and a breadth of 10-18 mm. The 
head is 2-3 mm. long, almond-shaped, with a groove like a 
sucker on either side. The mature segments have a length 
of only 5-6 mm. There have been reported as many as 4200 



154 



INFECTIONS. 



segments in a single parasite. The uterus is described as 
rosette-shaped, resembling an armorial lily, and is situated in 
the centre of the segment. The uterus presents some 4-6 
convolutions on either side. The male and female genital 
openings are located behind the uterus, on the flat side in the 
middle of the proglottis. The eggs are oval, length about 
. 0.07 mm., width 0.045 mm., characterized by a thin membrane 
and a lid (operculum). The eggs become brown upon expos- 
ure to water or air. 

Occurrence : The ^'measles^^ (plerocercoids) of the bothrio- 
cephalus latus occur in the muscles and intestines of fish, 
especially the pike, carp, and salmon. The parasite is not 
killed by subjecting infected fish to the action of smoke, salt, 
or freezing. These may develop into mature tapeworms in 
the dog, cat, and man. Infection from vegetables contami- 
nated with eggs or measles, through irrigation, has been sug- 
gested as an explanation for the cases occurring in individuals 
who do not eat fish. 

Infection with the parasite has been found, in this country, 
only in emigrants. 

Bothriocephalus cordatus has been found in dogs, walrus, 
and seals, in Iceland, and may infect man. 

Bothriocephalus leguloides : Found chiefly in eastern Asia. 

Bothriocephalus cristatus has been found only occasionally 
in man. 

DISTOMIASIS. 

Distomiasis is a disease caused by trematodes. 

Trematodes, or flukes, are flat, sometimes cylindrical para- 
sites, often resembling in shape the tongue or a leaf. The 
disease is very rare in the United States. 

The following are the more important varieties of the flukes: 

Distoma hepaticum, the liver fluke, leberegel (German), 
douve (French). Found rarely in man, commonly in the 
liver of the sheep, especially in Arabia. Huber says that ^'in 
the Munich abattoirs not a single sheep among many thous- 
ands is found free from the liver fluke." The disease is 



DISTOMIASIS. 



155 



very rare in the United States. The parasite exists in the 
immature stage in the snail, from which individuals may be- 
come infected through eating contaminated grasses or vege- 
tables (cress). 

In the liver the parasite produces symptoms mechanically, 
through obstruction of the biliary passages. Sometimes the 
parasite is found in the subcutaneous cellular tissue, apparently 
from infection through the skin. 

Distoma magnum (Bassi) : Length, 57-73 mm. ; width, 
24-35 mm. Found most frequently in deer in Italy and in 
cattle in the United States. The parasite does not occur in 
man. For a long time it was confounded with the distoma 
hepaticum. 

Distoma lanceolatum ( Mehlis) : Smaller than the liver fluke. 
Occurs commonly in the ruminants. A few cases have been 
reported in man. 

Distoma Buskii i Lankester) : didoiaa cran um ( Busk ). Larger 
than the liver fluke. Infection probably occurs through 
eating salads, fish, or oysters contaminated by the eggs (Cob- 
bold). The parasite is encountered most frec|uently in Asia. 

Distoma Sibiricum (^AVinigradolf* ) : Found in man in Tomsk. 
Length, 13 mm. ; width, 3 mm. 

Distoma pulmonale (Baelz) : 8-10 mm. long and 5-6 mm. 
wide. Occurs most frequently in the lungs. 

The sijinptoms are cough, with the expectoration of reddish- 
brown sputtim, resembling the intestines of fish. The sptitum 
contains the eggs in large numbers and sometimes the parasite. 

The parasite has been found in the liver-tissue, but not in 
the biliary passages. 

Infection of man occurs most frequently in Japan. Cases 
of infection of the cat and dog have been reported in the 
L^nited States (AVard). 

The eggs are 0.1 mm. long and 0.05 mm. Avide. They 
are frequently found in the sputum, sometimes in the brain, 
liver, omentum, mesentery, mediastinum, and diaphragm. 

Distoma spatulatum (Leuckart): Distoma eiidciiuci'nt (Baelz). 
Length, 11-12 mm. ; breadth, 2-3 mm. Found commonly in 
the liver of the cat, sometimes in man, especially in Japan. 

The symptoms are increased hunger, sensation of pressure 



156 



INFECTIONS. 



in the epigastrium, and marked enlargement of the liver and 
spleen ; later, sometimes only after several years, there is 
diarrhoea, sometimes with the passage of blood, ascites, oedema 
of the lower extremities, and cachexia. 

Distoma conjunctum (Cobbold) has been found in the biliary 
passages of man in Calcutta (McConnell). A similar fluke 
has been found in the American fox. 

Distoma heterophyes (v. Siebold) : 2 mm. long and 1 mm. 
wide. Probably often overlooked on account of its small size 
(Huber). The skin of the parasite is covered with spine-like 
scales. The eggs are 0.03 mm. long and 0.17 mm. thick. 
Cases of infection have been reported from Cairo and Alex- 
andria. 

Distomum hsematobium (Bilharz) : Bilharzia hcematobia 
(Cobbold). Found in various parts of Africa, where infec- 
tion of man occurs through bathing. 

The parasite and eggs are found especially in the urinary 
bladder. The dangers arising from infection have probably 
been exaggerated. The male parasite, which is the shorter 
and thicker, receives the slender female into a canal (canalis 
gynsecophorus) formed by a turning in of the abdominal bor- 
ders, the anterior extremity of which contains the sexual 
opening. The eggs are 0.12 mm. long and 0.04 mm. wide, 
and are characterized by a short spine at the end or to one side. 

Amphistomum hominis : Length, 5-8 mm. Has been found 
in the cecum and colon of man in India. 

Amphistoma hawkesii and amphistoma collinsii have been 
found, respectively, in the elephant and horse, in India. 

Distomiasis — symptoms : The symptoms depend largely upon 
the location of the parasite, which varies in different species. 
The parasite may be in the intestine, bile-ducts, gall-bladder, 
liver, lungs, spleen, bloodvessels, kidneys, ureters, or mesen- 
tery. The more common symptoms are diarrhoea, dysentery, 
hsematuria, cough, asthma, pyelonephritis, and pyonephritis. 

The diagnosis of distomiasis depends upon the symptoms ; 
but more especially upon the discovery of the parasite or eggs 
in the faeces, urine, or sputum. 

Distomiasis — treatment : Male fern, in the form of the 



NEMATODES. 



157 



ethereal extract or oleoresin, is the remedy in most common 
use. In the treatment of infection by the distoma hsemato- 
bium (Bilharz), Fourquet recommends the exhibition of male 
fern, and in bad cases irrigation of the bladder with a solution 
of bichloride of mercury. 

Other remedies are benzene or picric acid (Heller), salicylic 
acid, salol, naphthalin, and thymol, administered internally. 

Ivectal injections of sulphuretted hydrogen or carbon dioxide 
have been recommended in cases of infection by the distoma 
haematobium or distoma pulmonale. It is supposed that 
absorption of the gas occurs through the hemorrhoidal, vesi- 
cal, and mesenteric veins, so that the agent comes into direct 
contact with the parasite. 

Flukes may be removed from the bowel by large rectal 
injections, best given through a colon tube, of solutions of 
alum, tannin, or creolin, used warm, in conjunction with 
internal medication. 

Further treatment is symptomatic. Anaemia may call for 
the administration of iron, either alone or in combination with 
bitter tonics. 

NEMATODES (Nematoid (Filiform) Worms). 

Ascaris lumbricoides : Round worm ; spulwurm (German) ; 
lombric (French). One of the most common parasites, occurs 
in all parts of the world, especially in warm countries, most 
frequently in children. Males, 15-25 cm. long; females, 
20-40 cm. long. The eggs are elliptical, 0.05-0.07 mm. long 
and 0.04-0.05 mm. wide, and may number 60,000,000 in a 
single parasite. 

The parasite is most frequently found in the small intes- 
tine. The usual number of parasites in an infected indi- 
vidual is 2-10; although as many as 5000 are reported to 
have been passed by an individual within three years. 

Round worm — etiology : Infection may be transmitted 
directly, by means of the hands, through unclean habits ; or 
indirectly, through contaminated food, since freezing or dry- 
ing, unless long continued, Avill not kill the eggs. 

Nineteen cases of abscess of the liver, due to the ascaris 



158 



INFECTIONS. 



lumbricoides, have been reported. The parasite probably 
opened the way for bacterial infection to cause the abscess. 

Round worm — symptoms : These may be entirely absent, 
even in the presence of large numbers of parasites. Itching 
of the nose is a common symptom, possibly due to a peculiar 
odoriferous principle in the parasite (Huber). Often there is 
anaemia caused by malnutrition. Various symptoms may be 
produced on the part of the alimentary canal : salivation, 
anorexia, nausea, vomiting (rarely of the parasite) ; diarrhoea, 
sometimes with bloody stools ; or constipation, obstruction of 
the bowel sometimes being caused by masses of parasites. 
Perforation of the intestine has been reported ; but many 
authors believe that the parasite can appear in the peritoneal 
cavity only in cases of ulcer of the intestine (typhoid fever, 
tuberculosis). Sometimes symptoms may be caused by the 
parasite finding its way into the bile-ducts, the vermiform 
appendix, stomach, oesophagus, glottis. Eustachian tubes, 
nose, rarely in the lachrymal ducts, urinary bladder, vagina. 
Fallopian tube, the peritoneal cavity, pleural cavity, or in 
abscesses. The parasite finds its way into the peritoneal and 
pleural cavities and the urinary bladder chiefly through fistulas 
communicating with the alimentary canal. 

More common are nervous symptoms, all varieties of which 
have been ascribed to this parasite. 

A positive diagnosis can be made only upon finding the 
parasite or its eggs. 

The prognosis is good under proper treatment. 

Prophylaxis : This calls for cleanliness, which may be diffi- 
cult to secure at all times, especially in children and the 
insane. Infected individuals should be instructed regarding 
the danger of contaminating food. It would be better if the 
faeces of such persons were disinfected or burned. Infection 
through the water-supply may be guarded against by boiling 
or filtering the water. 

Round worm — treatment : Santonin is the remedy in com- 
mon use, in doses of gr. j-iij to an adult ; gr. J-j to a child 
two years old. The remedy may be given in combination 
with castor oil or calomel, or in the form of a confection fol- 
lowed by a laxative. 



yEMATODES. 



159 



Other remedies are the fluid extract -pigelia. senna, oil 
of chenopodiuEQj infusions of cus-(» and kamala, and turpen- 
tine. 

Ascaris mystax (Zeder): Males, 4o-60 mm. long; females, 
120-180 mm. long. Upon the sides of the head there are 
two wing-like appendages. The eggs are spherical, 0.068- 
0.072 mm. in diameter. The parasite is commonlv f jund in 
the dog and cat, and has been found in man. 

Ascaris maritima f E. Leuckart ) : A female 43 mm. in length, 
not yet mature, vomited by a child in Greenland, has been 
reported by Leuckart. 

Oxjmris vermicularis, Ascaris vermicularis ; pin-worm ; 
seat-worm ; thread- worm. Males, 3-5 mm. long, posterior ex- 
tremity blunt and curled up ; females, 10 mm. long and 0.6 
mm. wide. Eggs, 0.05 mm. long and 0.02 mm. ^-ide. The 
parasite may contain from ten to twelve thousand eggs. 



Fig. 26. Fig. 27. 




Oxyuris vennicuTans. a. male: h. Eggs of oxynri; vermicularis. X 275 
female ; natural size EictLhorst) . " " after Eiehhorst^. 

These are usually passed after the parasite leaves its host. T. 
Jaksch claims to have found the eggs in the fsces in almost 
all cases ; but other observers (O. Leichtenstern. Lutz. Huber) 
have failed to find them. The parasite is found in the small 
intestine. After impregnation the female passes into the 
large intestine. Eggs may sometimes be found in the lower 
part of the colon. As a rule, however, the eggs are not de- 



160 



INFECTIONS. 



posited until the female has passed out of the alimentary 
canal. 

Etiology : Infection follows ingestion of the eggs of the 
parasite. Food may be contaminated. More frequent is 
direct infection througli unclean habits. The eggs are intro- 
duced into tlie mouth from the hand, which has become con- 
taminated, as a rule, through the efforts to relieve the itching 
caused by the parasite. 

Pin-worm — symptoms : The most prominent symptom is 
the burning sensation, the itching of the anus, caused by the 
sharp end of the female. The symptom may not appear 
until the individual has retired at night. Numerous symp- 
toms on the part of the nervous system, including convulsions, 
may be caused, in a susceptible individual, by the irritation of 
the parasite. 

The diagnosis is usually made by an examination of the 
anus, which will reveal the parasite. Should the parasite not 
be found upon examination, it may be seen after the injection 
of cold water. 

Prognosis is good. 

Prophylaxis demands cleanliness. As stated, infection is 
usually carried to the mouth by the unclean hand that has been 
used to relieve the itching of the anus caused by the parasite. 

Treatment : Usually an enema of Avater, plain or containing 
salt, alum, or creolin, Avill suffice to remove the parasite. 
Parasites in the small intestine may be removed by the ad- 
ministration of santonin and a laxative. 

Schmitz reports success w^ith naphthalin. After the admin- 
istration of a purgative, naphthalin in powder (0.15 for a 
child one and a half years old to 0.4 at twelve years), given 
four times a day for two days, and repeated after eight days, 
is effectual. 

Trichocephaliasis : Infection by the trichocephalus hominis 
(Schrank) ; trichocephalus dispar (Rudolphi); whip-worm. 
Named "trichocephalus" from the resemblance of the head to 
a hair. The tail end is much larger than the head. The 
parasite is 40-50 mm. long and 1.0 mm. wide. The male is 
shorter than the female, and has a body that is rolled up into 



NEMATODES. 



161 



a spiral. The eggs, 0.05 ram. in diameter, are lemon-shaped, 
brown colored, with thick shells and projecting clear extremi- 
ties. There may be as many as 58,000 eggs in a single para- 
site (Leuckart). The eggs resist drying and changes in 
temperature. Infection occurs chiefly through the ingestion 
of contaminated food or water. The number of parasites in 
an individual usually varies from 3 to 10, although more 
than a thousand have been reported (Rudolphi). The para- 
sites are usually found in the caecum and appendix vermi- 
formis^ large intestine, and sometimes in the lower part of 
the small intestine. 

Whip-worm — symptoms : Frequently there are no symp- 
toms. The intestinal irritation may cause diarrhoea, some- 
times bloody stools, nausea, vomiting, and emaciation, with 
anaemia and loss of strength. JsTervous symptoms may be 
more or less marked. 

The diagnosis is made by the discovery of the eggs or the 
parasite ; but the parasite does not often appear in the stools. 

The prognosis is good as a rule, although sometimes the 
parasite is not easily dislodged. 

Prophylaxis calls for cleanliness, that infection may not 
occur directly or food or drink become contaminated. A 
contaminated water supply should be remedied, or the water 
filtered or sterilized by boiling before it is used. 

Treatment : This is the same as that outlined for oxyuris 
vermicularis, except that it is important that the enemata 
should be sufficiently large to reach the cvecum. A combi- 
nation of male fern internally and rectal enemata is some- 
times effectual where other means fail. 

Ankylostomiasis ; Dochmiasis • Egyptian chlorosis ; tropical 
chlorosis ; brickmakers' anaemia ; miners' cachexia ; caused 
by the anhylostomum duodenale (Dubini), strongylus quadri- 
dentatus (v. Siebold). Female, 6-18 mm. long and 1.0 mm. 
wide; male, 6-11.5 mm. long and 0.5 mm. in diameter. There 
are more females than males. During copulation, wliich lasts 
for several days, the union bet\veen the parasites is so firm that 
attempts at forcible separation may result in tearing the body 
of the male. The eo^o^s are 0.66 mm. lonar and 0.03 mm. in 
11— p. M. 



162 



INFECTIONS. 



diameter. The number of eggs passed is very great ; in an 
evacuation of a pint Leichtenstern estimated the number of 
eggs at four millions. After escaping from the intestinal canal 
the eggs become encysted. When these are ingested they lose 
their outside covering through digestion in the stomach, and 
the embryos become attached in the intestine, usually in the 
jejunum, more rarely in the duodenum, exceptionally in the 
pylorus, stomach, or ileum. 

Tropical chlorosis — etiology : The disease occurs in those 
brought into intimate contact with soil contaminated by fseces 
(brickyards, mines, tunnels), largely through infection of the 
food by dirty hands, or the use of water containing eggs of 
the parasite. Lutz has reported numerous cases occurring in 
children in Brazil. The number of parasites present in an 
individual is rarely less than a hundred, and may be over 
three thousand (Grassi). 

Symptomatology : The parasite extracts blood from the 
intestinal wall, living upon the serum of the blood. Conse- 
quently there are anaemia, sometimes the appearance of blood 
in the stools and evidences of intestinal irritation ; and pain 
and tenderness in the region of the jejunum. There may 
be fever, salivation, disturbances (increase or decrease) of the 
appetite, nausea and vomiting, sometimes tympanites. A very 
common symptom is oedema, beginning in the eyelids and 
becoming general. With weakness of the heart cyanosis may 
appear. The number of red blood-corpuscles may be de- 
creased to less than a million to the cubic millimetre, with a 
corresponding decrease in the haemoglobin. With this there 
may or may not be leucocytosis. Men may show impotence ; 
women, amenorrhoea. 

The diagnosis depends upon the discovery of the eggs, 
as a rule, which are discharged in enormous numbers with 
the faeces. Spontaneous discharge of the parasite rarely 
occurs. 

The prognosis depends upon the condition of the patient at 
the time treatment is begun. Even severe cases may recover 
after removal of the parasites. 

Prophylaxis : Food should be thoroughly cooked ; the Avater 
pure, boiled ; and, above all, the hands should be washed 



NEMA TODES. 



163 



before eating. Infected workmen should be excluded from 
non-infected localities. 

Tropical chlorosis — treatment : The preparatory treatment 
is the same as that for tape^Yorm in general. Thymol is 
highly recommended : four drachms divided into two powders, 
taken two hours apart, followed in two hours by a dose of 
castor oil or calomel. Male fern has been largely used. 
After removal of the parasite tonics, especially iron, should 
be given. 

Eustrongylus gigas is found in various carnivorous animals, 
sometimes in herbivora, and has been reported in man. The 
male is 25-35 cm. long; the female, 25-100 cm. long and 
5-12 mm. in diameter. The color is reddish. The parasite 
occurs especially in the kidney, sometime? in the bladder, and 
is recognized by finding the eggs in the urine. The eggs are 
66 /J. long and 43 /j. in diameter, broAvn colored. On the 
upper surface are little depressions with a surrounding ele- 
vated border. The poles are flat. 

Dracontiasis, Guinea-worm disease, caused by the dracun- 
culus Persarum (Kampfer), filaria medinensis (Gmelin), 
Guinea-worm. The parasite is 50-100 cm. long and about 
1.7 mm. in diameter. Only the female was known until 
Charles found a pair in the act of copulation, in the mesen- 
tery. The male was about one-third the length of the female 
(Huber). It would seem that the vagina is in the centre of 
the body of the female and after copulation becomes occluded. 
It is probable that both male and female find their way from 
the intestine to the mesentery, death of the male then occur- 
ring after copulation, the female entering the connective 
tissue and travelling toward the feet. In tlie great majority 
of cases the female parasite finds its way to the surface of 
the foot about the dorsum or malleoli, rarely in the legs or 
thighs, very rarely about the thorax. The embryos are dis- 
charged by rupture of the parent worm. The eggs then find 
their way into water, where they enter the body of a small 
fish, and grow to be about 2.0 mm. long, when they are taken 
into the body of man through the medium of contaminated 



164 



INFECTIONS. 



drinking-water. Some investigators believe that infection of 
man may occur directly through the skin from contact with 
contaminated water. 

Guinea-worms — symptomatology : Symptoms are absent 
until the parasite reaches the skin, when there are localized 
pain, redness, and swelling, and later perforation of the skin 
and the discharge of embryos. 

The diagnosis rests upon the discovery of the embryos or 
the parasite. 

The prognosis as a rule is good. 

Treatment : The parasite must be carefully extracted when 
it appears at the surface. This should be done very gradually 
by winding the parasite upon a piece of wood, a little each day 
for a number of days, to avoid rupture of the parasite and the 
discharge of embryos. Good results have been claimed for 
the injection of bichloride of mercury, 1 : 1000,- into the 
parasite or its burrow. Where it is impracticable to open the 
burrow, carbolic acid, 1: 15, may be applied externally by 
means of compresses. 

Filariasis, a disease caused by the filaria sanguinis hom- 
inis (Lewis) ; filaria Wuchereri (d'Silva and Lima) ; filaria 
Bancroft] (Cobbold). The chief varieties of this parasite are : 

1. Filaria sanguinis hominis nocfwrna — male, 83 mm. long and 
0.4 mm. in diameter; female, 155 mm. long; eggs, 38 x 14 /j.. 

2. Filaria sanguinis hominis diurna, or majoixi, distinguished 
by being found in the blood only during the daytime. 3. 
Filaria sanguinis hominis minora, or perstans, only the em- 
bryos of wliich are known, 0.2 mm. long. 

Filariasis is a disease of the tropics, occurring most fre- 
quently in Brazil, the West Indies, and also in Mexico, South 
America, the South Sea Islands, Japan, Australia, China, 
India, Egypt, and Spain. The disease is seldom seen in the 
southern part of the United States. 

Symptoms : These may be entirely absent. There may be 
leucocytosis, chyluria, or hsematochyluria, and discharge of 
the parasite and eggs with the urine. The parasite is be- 
lieved to cause at least some cases of elephantiasis Arabum, 
lymph-scrotum, lymph-vulva, chylous ascites, chylous diar- 



NEMATODES. 



165 



rhoea, possibly the sleeping-sickness of Africa ; and a case of 
filarial hsemoptysis has been reported (Yaniane) in which 
filarise were found in the expectorated blood. Some observers 
believe that the mosquito is the intermediate host. 

The diagnosis depends upon the discovery of the filaria in 
the blood, which should be examined both day and night. As 
a rule the parasite appears in the blood only at night ; but in 
some cases it has been found present only during the day, 
especially in individuals who sleep during the day. The 
examination of the blood should be made with a low-power lens. 

Prognosis : The mortality is not high. The loss of chyle 
may lead to death from marasmus. 

Filariasis — treatment : This is largely symptomatic. Cures 
have been reported after the use of gallic acid, picro-nitrate 
of potassium, iodide of potassium, benzoic acid, quinine, and 
methylene-blue. A cure may or may not follow removal of 
the parasite. The use of tonics, especially iron, is usually 
called for. 

Trichiniasis. 

Trichiniasis, trichinosis, is due to the trichina spiralis (Rich- 
ard Owen). 

The infection occurs in man through the use of trichinous 
pork, and has been produced experimentally in dogs and cats. 
Ingested muscle trichinae are liberated by digestion in the 
stomach, and in the intestine become sexually mature within 
about three days and full grown within a week. The males 
are 0.8— l.e5 mm. long; the females, 1—4 mm. long. The 
genital opening of the male is at the extremity ; that of the 
female is in the neck. Soon after copulation the male dies; 
the female continues to live, as a rule, about a month longer. 
The embryos, 0.08-0.12 mm. in length, leave the shell before 
parturition and are born directly into the intestinal follicles, 
in which the female trichinse may sometimes be found inserted. 

The embryos migrate to the muscles, probably along the 
lymph-channels ; according to some authors, along connective- 
tissue routes ; and they have been found in the blood. In the 
muscles they destroy some of the contractile substance, and 
after reaching a length of about 0.06 mm. they roll up into a 



166 



INFECTIONS. 



spiral (Fig. 28), become encapsulated, and continue to grow 
until they reach a length of about 1.0 mm. In this condition 
they may remain alive for a number of years — seven to ten, 
even thirty years in reported cases. 

Trichinosis — symptomatology: Soon after the ingestion of 
infected meat there may be anorexia, nausea, vomiting, 
abdominal pain, and diarrhoea, sometimes with bloody stools. 
Usually there are no symptoms until about the end of the 
first week, when there may be anorexia, malaise, flushes of 



Fig. 28. 




Miisck'-libre with tricbinee (Heller). 



heat, and chilly sensations, sometimes with sw^eating, thirst, 
and diarrhoea. An early symptom is muscular weariness. 

With the invasion of the muscles by the parasite, about the 
second week, the afPected muscles become tender, painful, 
stiff, swollen, and hard. Usually there is fever, which may 
reach 104°-106° F., usually highest from the ninth to the 
eleventh day (Mosler). Fever may be absent even when 
there is considerable affection of the muscles. 

(Edema, appearing first in the eyelids, usually is present 
after the first week, and lasts as a rule two to five days in the 
eyelids, longer in the extremities. There may be oedema of 
the scrotum or prepuce, sometimes ascites. 

On the part of the resjyiratoi^y system there may be bronchial 
catarrh, pneumonia, especially hypostatic pneumonia. Affec- 
tion of the respiratory muscles may lead to dyspnoea ; affection 
of the laryngeal muscles may cause hoarseness and aphonia. 
Sometimes there is oedema of the glottis. 

On the part of the nervous system insomnia is a prominent 
symptom. There are often headache, and sometimes loss of 
the tendon-reflexes. 



NEMA TODES. 



167 



Examination of the blood reveals a marked increase of the 
eosinophile cells in association with leucocytosis. 

Diagnosis : The symptoms present may lead to the suspicion 
of trichiniasis. The differential diagnosis concerns especially 
poisoning by meat and sausage, and acnte polymyositis (Un- 
verricht). A positive diagnosis can be made upon the dis- 
covery of the parasite in the stools, especially after purgation, 
or in the muscles of the patient, or in a remnant of meat 
from which the patient has been eating. There are leucocy- 
tosis and a large increase of eosinophile cells. 

Prognosis : The mortality varies from 2 to 30 per cent., 
probably as a rule about 20 to 25 per cent. 

Prophylaxis : This in man may be secured by thoroughly 
cooking pork or abstaining from its use altogether. Infected 
animals should not be used as food. Hogs should not be fed 
on the offal of slaughter-houses, and it has been suggested 
also that they should be protected from rats, which some 
believe capable of communicating the disease to hogs. 

Tricliinosis — treatment : Cases seen soon after the inp:estion 
of infected meat may be cured by lavage of the stomach and 
the administration of a pui-gatii'e. Even later in the course 
of the disease purgation may be resorted to in order that 
fewer egg^s may be deposited within the body. 

Following the purgation remedies may be given to kill the 
parasite in the intestine. For this purpose the remedies in 
common use are keratin-coated pills of the sulphocarbolate 
of sodium, two grammes every four hours, and salicylic acid, 
one gramme three times a day. Diarrhoea, which is not too 
severe, should be encouraged, especially as long as the parasite 
may appear in the stools. The treatment of muscle trichina 
is purely symptomatic. 



CHAPTER II. 



DISEASES OF THE ORGANS OF DIGESTION. 
DISEASES OF THE MOUTH. 

GENERAL CONSIDERATIONS. 

Diseases of the mouth present symptoms which vary largely 
according to the part of the mouth affected. The buccal 
secretion is furnished by the salivary and mucous glands, and 
gives normally an alkaline or a neutral reaction. An acid 
reaction may be caused by acid fermentation. Decomposition 
of food may cause the breath to become foetid. A bad odor 
from the mouth is known as stomatodysodia. In infants, espe- 
cially during the first three or four months, the buccal secre- 
tion is slight, and the mouth is rendered liable to infection by 
frequent insults. In adults the secretion is diminished, espe- 
cially in the infectious diseases and whenever there is fever. 
In such cases a coating forms on the tongue. Mouth-breathing, 
through drying the buccal secretion, may cause apparent 
diminution of the secretion. 

Hypersecretion (salivation) is found in many diseases, espe- 
cially in local inflammatory diseases of the mouth. A condi- 
tion simulating salivation may be caused by obstruction of 
nasal respiration or motor disturbances preventing the closure 
of the lips, or by inability to swallow. 

General symptoms : Diseasen of the vestibidum and cheek 
pouches are characterized by difficult or painful mastication. 
Diseases of the tongue show not only difficult or painful masti- 
cation, but also difficulty in swallowing solid food. Diseases 
of the soft palate, arches of the palate, and isthmus of the fauces 
offer difficulty in swallowing. Motor disturbances of the 
velum palati, and perforations and defects of the hard or soft 
palate, permit the entrance of food into the naso pharynx and 

168 



STOMATITIS CATARRHALIS 



169 



its expulsion through the nose. 3fotor disturbances of the epi- 
glottis and root of the tongue permit the entrance of food into 
the larynx and trachea. Cleft palate and defects of the palate, 
presenting a communication between the buccal and nasal 
cavities, and diseases of the velum palati, interfering with 
shutting off the naso-pharjnx, give rise to a 7iasal tone of 
voice. When the normal communication between the buccal 
and nasal cavities is partially or entirely cut off (tumors) the 
nasal tones are absent. Disease of the tongue affects especially 
the enunciation of the explosives and sibilants. Diseases of 
the vestibule, the cheek-j)ouches, and especially of the lij)s, affect 
the enunciation of the vowels and labial consonants. 

Effects of drugs : The salivary secretion may be diminished 
by atropine or increased by pilocarpin, muscarin, eserin, etc. 
Iodine and bromine, or their salts, increase the salivary secre- 
tion and cause swelling of the mucous membrane, especially 
about the gums. A yellowish-white coating appears at the 
edges of the gums and on the teeth, and the breath has a 
peculiar odor. Phosphorus-poisoning causes similar symptoms 
and early involvement of the alveolar processes, periostitis, 
and necrosis of the maxillary bones. Mercurial poisoning 
causes stomatitis with salivation (see Stomatitis Ulcerosa). 
Chronic lead-poisoning causes swelling of the mucous mem- 
brane, especially at the edges of the gums, with a deposition 
of lead, constituting the " lead-line.'^ Poisoning by silver 
(argyria) causes staining of the mucous membrane of the 
mouth and of the skin of the body, the stain appearing in 
blackish-brown punctate spots. 

Eruptions : Herpes frequently involves the mucous mem- 
brane of the mouth. Many diseases, especially the acide 
infections, show an eruption in the mouth. 

Injuries of the mouth may be caused by the teeth or by 
external violence, burns, or caustics. 

STOMATITIS CATARRHALIS (Acute, Simple, or Erythematous 

Stomatitis;. 

Etiology: Improper care of the mouth, especially of the 
teeth, and irritants of all sorts, act as causes. Infants are 



170 DISEASES OF THE ORGANS OF DIQESTION. 



especially liable to the disease, because the saliva is small in 
amount and comparatively inactive, and also because of the 
habit of putting things into the mouth. In adults the use of 
alcoholic beverages is a prominent etiological factor. 

Symptomatology : The muGoiis membrane is swollen^ dry, 
and inflamed ; later, the salivary secretion becomes increased 
and there is pain. There may be actual salivation and spongy 
gums, with falling out of tlie teeth. In severe cases the 
tongue may become coated and swollen. The sense of taste 
is diminished or lost. There may be fever, and nutrition may 
be impaired, especially in infants, who are not able to nurse 
because of the soreness of the mouth. 

Treatment : The mouth should be kept clean and carious 
teeth should be properly treated. Mouth-washes containing 
antiseptics, such as thymol (1 : 2000), alum (1 : 200 to 1 : 500), 
permanganate of potassium (1 : 2000 to 1 :5000), chlorate of 
potassium (1 : 25 to 1 : 100), are useful. The local application 
of iodoform has been highly recommended for ulcerations. 

STOMATITIS ULCEROSA. 

Etiology: Stomatitis ulcerosa occurs most frequently in 
children, especially from five to ten years of age. Sometimes 
the disease becomes endemic in children's hospitals or wherever 
individuals are crowded together. It has been suggested that 
such endemics may be outbreaks of foot-and mouth disease, or 
of some disease showing complications on the })art of the 
mouth. Besides the causes enumerated in the etiology of 
stomatitis catarrhalis, the following deserve special mention as 
causes of stomatitis ulcerosa : the accumulation of tartar on 
the teeth, syphilis, rickets, diabetes mellitus, tuberculosis, and 
mercurial poisoning. 

Miller found a motile bacillus and spirochsete, always asso- 
ciated, in carious teeth ; and the same organisms were found 
by Bernheim in thirty cases of ulcerative stomatitis in the 
deposit on recent ulcers. 

Symptomatology : The symptoms of stomatitis catarrhalis 
are usually present in aggravated degree, and in addition 
there is ulceration, which always begins on the gums, usually 



STOMATITIS APHTHOSA. 171 

about the lower incisor and canine teeth. The ulcers extend 
to involve the cheeks and lips, frequently the tongue and 
floor of the mouth. There is a peculiar foul odor, with pain 
and salivation. Difficulty in speaking, che\ying, and swallow- 
ing 13 marked. 

Treatment : The cause should be removed. The mouth 
must be kept clean. Early in the disease antiseptic mouth- 
washes may be advantageously used, such as solutions of 
potassium chlorate (1:25), borax (1:30), potassium perman- 
ganate (1 : 2000 to 1 : 5000), and tincture of myrrh or of 
rhatany (gtt. xx-xxv in a wineglassful of water). Early, 
before sloughing, the borders of the gums may be touched 
with the stick of nitrate of silver. Later the local applica- 
tion of iodoform, or the insertion of iodoform-gauze between 
affected contiguous portions of the tongue, lips, and cheeks, is 
recommended, with the internal administration of potassium 
chlorate, 2.0-5.0 fgr. 30-75) daily. Periosteal abscesses 
should be evacuated and sequestra removed. Xutrition must 
be maintained, if necessary, by feeding throtigh a tube. 

STOMATITIS APHTHOSA Aphtha; Stomatitis Herpetica; 

Canker (. 

Definition : An acute infectious disease of the mucous mem- 
brane of the mouth characterized by the early appearance in 
the epithelium of small circumscribed white fibrinous spots 
surrounded by a bright-red line. 

Etiology : Stomatitis aphthosa occurs especially in children 
during the first dentition. But dentition is not a cause of 
aphtha. The disease is believed by some to be a form of 
herpes occurring in the mouth. Friedreich, by the injection 
of the toxins of the streptococcus and bacillus prodigiosus, 
produced herpes of the face in seven cases and aphtha in two 
cases. Friinkel found the staphylococcus citreus and flavus 
(see Foot-and-mouth Disease). 

Symptomatology : The white or yellowish fibrinous patches, 
sharply circumscribed, round, or oval, appear early, each sur- 
rounded by a slightly elevated red border. These cause a 
burning sensation and actual pain, and when the patches are 



172 DISEASES OF THE ORGANS OF DIGESTION. 



numerous or extensive there may be marked interference with 
mastication, deghitition, and speech. 

Diagnosis : Stomatitis aphthosa should be differentiated 
especially from foot-and-mouth disease, in which there are 
more severe stomatitis and greater depression. The diseases 
are believed by some investigators to be closely related. 

The prognosis is good. 

Prophylaxis : Most cases may be prevented by cleanliness of 
breasts, or nursing-bottles, especially the nipples. The mouth 
should be kept clean. This should include attention to the 
teeth, the temporary as well as the permanent set, and the 
proper treatment of carious teeth. 

Treatment : The mouth may be washed with a solution of 
borax in water, or boric acid in glycerin and water. Almost 
any mild antiseptic solution may be used. Cleanliness is of 
most value. 

BEDNAR'S APHTHA (Bednar's Plaques). 

Characteristics : Circumscribed thinning of the epithelium 
with sharply defined yellow spots on the posterior lateral 
border of the hard palate. The etiology is not clear. The 
thinning of the mucous membrane has been held to be due to 
the general desquamation following l)irth, to pressure of the 
tongue in nursing, and to injury of the mucous membrane in 
cleansing the mouth. A similar thinning of the mucous mem- 
brane has been described in the stillborn. Care should be 
exercised to avoid trauma in cleansing the mouths of infants. 
Recovery from Bednar's aphtha occurs spontaneously in the 
course of a few days. 

STOMATITIS GANGRENOSA (Noma; Cancrum Oris). 

The gangrenous process begins on the cheek, near Steno's 
duct, and rapidly spreads. 

Etiology: Various micro organisms have been isolated from 
the necrotic tissue. Bacilli have been described especially by 
Schimmelbusch (1889) and Foote (1893); but the etiological 
relation of none of these has been definitely established. 

Since the immediate cause is not known, Forchheimer 
holds that the predisposing cause is the more important. 



STOMATITIS MYCOTICA. 



173 



The disease prefers children — those that are anaemic and not 
well nourished. Adults may be attacked. Noma has fol- 
lowed measles in about half the cases of noma reported, and 
in other instances has occurred after scarlatina, typhoid fever, 
pneumonia, and ulcerative stomatitis (ptyalism). 

Noma — symptomatology : The disease comes on with the 
usual symptoms of stomatitis. A blue vesicle appears on the 
mucous membrane opposite the first or second molar tooth, 
near Steno's duct, later becoming darker in color. There is 
the characteristic odor of ^angrene. The cheek shows exten- 
sive swelling, with great hardness from infiltration and at the 
same time pallor. The vesicle breaks down in a gangrenous 
process, which rapidly extends to perforate the cheek and 
cause great destruction of tissue. Finally a line of demarca- 
tion may form, the necrosed tissue be cast off, and recovery 
take place, often with great deformity. More frequently 
death ensues from exhaustion, sepsis, or malnutrition. The 
disease usually lasts about one or two weeks. Rarely the 
process may begin in the anterior sublingual region, still 
more rarely upon the external genitals, the anus, or the 
auricle. 

Diagnosis : Usually easy. At first there might be some 
hesitation in the differentiation between the early stage of 
stomatitis gangrfenosa and stomatitis ulcerosa. 

Prognosis : As a rule bad. The mortality has been given at 
70 per cent. Cases that recover usually show great deformity. 

Noma — treatment : Early extirpation with the knife or 
cautery has been recommended ; but often gangrene recurs 
in the wound. Sepsis and malnutrition call for special at- 
tention. 

STOMATITIS MYCOTICA (Thrush; Stomatitis Parasitica ; Soor 
(German); Muguet (French)). 

Thrush was the first disease proven to be due to the action 
of vegetable parasites. 

The specific cause of the disease is the thrush-fungus, 
called by its discoverer the Oidium. albicans, which has since 
been placed by some among the highest of the fungi, by 



174 DISEASES OF THE ORGANS OF DIGESTION. 



others among the moulds, while still others believe it to 
belong to neither class. 

Stomatitis mycotica occurs especially among children, some- 
times among invalids. Lack of cleanliness, especially with 
regard to the mouth, is a predisposing cause. Thrush seems 
to show a preference for individuals who live upon a milk- 
diet. 

Thrush — symptoms : The disease appears first as small 
white points or patches upon an otherwise apparently healthy 
mucous membrane. These patches extend rapidly. The 
membrane may be removed readily. There is pain, which 
may interfere with the child's nursing and thus cause mal- 
nutrition. 

Prognosis : Especially in individuals who are ill, the nutri- 
tion may be still further interfered with by the occurrence of 
thrush, which thus sometimes becomes a forerunner of death ; 
but as a rule the prognosis is good. 

Prophylaxis : Thrush may be prevented by proper care of 
the mouth. The mouth should be kept clean. 

Thrush — treatment : Food or medicine containing sugar 
must be avoided. The mouth should be thoroughly cleaned, 
probably best with a solution of borax in water or glycerin ; 
a mild solution of potassium permanganate or potassium 
chlorate; or of methylene-blue ; or an astringent mouth-wash 
(see Stomatitis Ulcerosa). 

The affections of the mouth by gonorrhoea, syphilis, tuber- 
culosis, glanders, leprosy, and actinomycosis, are treated of, 
respectively, among the Infections. 

Among the animal parasites found in the mouth may be 
mentioned the larvae of eggs of flies ; the oxyuris vermicu- 
laris ; cysticerci ; echinococci ; filaria Medinensis, and trichina. 

DISEASES OF THE TONGUE. 

The tongue shows great resistance to disease, notwithstand- 
ing its constant exposure to " insult.^' 



ACUTE GLOSSITIS— LIXGUA GEOGRAPHICA. 175 



ACUTE GLOSSITIS. 

Acute glossitis is cdu^td most frequently by traumatism, 
burns, and foot-and-mouth di-ease. Abscesses of the tongue 
may occur as complications of stomatitis or from Avouuds. 
occasionally in some of the infections, especially typlinid 
fever, erysipelas, smallpox, and anthrax. There are jiaiii. 
salivation, and enlarpenient of the trjngue. The pre-ence uf 
pus is rarely revealed hy liuctuati<jn. There may be fever, 
headache, and L tss of appetite. 

Diagnosis calls for dilferentiation from hypertrophy or 
lymphangioma and syphilitic giimmata. 

The treatment is surgical. The part may be scarified or 
incised, and idoform-gauze applied. 

CHRONIC GLOSSITIS. 

A chronic enlargement of the tungue may result from re- 
peated attacks of acute glossitis or from uiyxcedema or cre- 
tinism. The treatmenf should address the underlying cau>e 
or disease. 

MACROGLOSSIA. 

Macroglossia, or enlargement of the tongue, is tisually con- 
genital ; sometimes due to lymphangioma or muscular hyper- 
plasia ; rarely to acromegalia. 

The treatment is surgical. The tongue may be reduced in 
size by the removal of a wedge-shaped piece. 

LINGUA GEOGRAPHICA Geographical Tongue; Mapped 
Tongue . 

Appearance : The tongue -h<'>v--. in this condition, smooth 
red patches denuded of e|")ithelium and bounded by Avliite 
margins, which shoA\' frequent variation- in outline, some- 
times disappearing entirely to reappear later. Usually tlie 
patient complains only r^f the accompanying sti;»matiti-. 

Diagnosis : Th^- u-'' rnqdiieal tongue should be dilfierentiated 
from a chromic -iqi-rriiial ghj-sitis. which causes more pain 
and runs a more chronic course : and from the mucous patches 



176 



DISEASES OF THE ORGANS OF DIGESTION. 



of syphilis, which shows less variation in outline and longer 
duration. 

Treatment : Medication is unnecessary, further than address 
to any accompanying stomatitis. 

ANGINA. 

Definition : Affection of the fauces, pharynx, and throat, 
especially of the fauces and tonsils, attended with pain, dys- 
phagia, and dyspnoea. 

Forms : Angina involving the fauces may be catarrhal, 
rheumatic, or herpetic; involving the tonsils: lacunar, fol- 
licular, or phlegmonous. Angina of the whole throat may 
be septic, gangrenous, erysipelatous, etc. 

The "sore throat" of scarlet fever, diphtheria, syphilis, and 
tuberculosis has received separate consideration. 

DISEASES OF THE TONSILS. 

ACUTE FOLLICULAR TONSILLITIS (Acute Catarrhal Angina ; 
Acute Amygdalitis; Croupous Tonsillitis; Lacunar Tonsillitis). 

Etiology : Numerous bacteria, especially the micro-organ- 
isms of pus and the micrococcus pneumonise croupos^e, have 
been found in the crypts of the tonsil, but not invading the 
tissue. Grrey, Edwards, and Severn traced an epidemic of 
follicular tonsillitis through the milk-supply to a single animal 
by bacteriological examinations, which revealed in the throat 
of an affected case and in the milk from the diseased animal 
the staphylococcus aureus and albus and the short form of the 
streptococcus pyogenes. Goodale has suggested that possibly 
the disease may be due to the absorption through the mucous 
membrane of irritating toxins formed in the crypts as in a 
test-tube. The cases in which the micrococcus pneumonise 
crouposse is found in pure culture usually show a sudden onset 
and a termination by crisis, resembling the picture seen in 
croupous pneumonia (Vent, Jaccoud). The pseudomem- 
branous angina, appearing about the fourth day of scarlet 
fever, usually shows the streptococcus upon bacteriologic 



ACUTE FOLLICULAR TONSILLITIS. 177 



examination. Cases of pseudodiphtheria also present the 
streptococcus, which is often very virulent. 

The disease prefers young adults, and occurs especially in 
spring and autumn, sometimes in epidemic form. 

Acute tonsillitis — symptomatology : Early the patient com- 
plains of tickling or burning in the throat. There is dyspha- 
gia, sometimes dysphonia. There may be salivation. The 
tonsils are inflamed, and on them are found yellowish-white 
spots, which may not be easily removed. The spots or patches 
of exudate are separated by apparently healthy tissue. The 
patches are usually confined to the tonsils and when removed 
do not leave a denuded surface. 

The general symptoms may be scarcely noticeable or quite 
severe. Usually the disease begins with chilly sensations ; 
sometimes with an actual chill. As a rule there are lassitude 
and malaise, sometimes severe prostration. There are head- 
ache and anorexia, sometimes nausea and vomiting. The 
temperature may reach 102°-105° F. The pulse and respira- 
tion are rapid. Examination of the blood shows marked 
leucocytosis. The spleen may be enlarged. The urine varies 
with the fever, and may contain albumin and casts. 

Acute tonsillitis — diagnosis : This concerns chiefly the 
differentiation from diphtheria. It is better to make a bacte- 
riological examination for the diphtheria bacillus before 
excluding diphtheria. In acute follicular tonsillitis there 
will usually be found streptococci or the micrococcus pneu- 
moniae crouposse. 

The prognosis is usually good. The rare fulminating septi- 
csemic forms may result in death. Pseudomembranous angina, 
especially that occurring in scarlet fever, may extend to the 
nose, ear, or larynx. Endocarditis and nephritis have been 
reported. 

Acute tonsillitis — treatment : This is symptomatic. For 
the toxic symptoms phenacetin afl()rds considerable relief, and 
may be given in gr. x doses, combined w^ith caifein and sodium 
bicarbonate, aa gr. j, repeated two or three times a day for a 
day or two. One of the best remedies is salicylate of sodium. 
Local treatment, especially cleansing the tonsil with antiseptic 
solutions, is of value. 
12- p. M, 



178 DISEASES OF THE ORGANS OF DIGESTION. 



SUPPURATIVE TONSILLITIS. 

See Quinsy. 

HYPERTROPHY OF THE TONSILS (Chronic Tonsillitis). 

Hypertrophy of the tonsils occurs especially in children, 
and has been found in the new-born. 

Symptomatology : The patients frequently have repeated 
attacks of acute tonsillitis and " catcli cold ^' on slight expos- 
ure. Usually there is mouth-breathing ; sometimes interfer- 
ence with breathing, rarely Avith swallowing. Occasionally 
hypertrophy of the tonsil causes torticollis. 

Diagnosis is easy. Distention of the tonsil from concretions 
or cheesy masses may be eliminated by careful examination 
with a probe. Malignant disease usually occurs later in life. 

Prognosis : As a rule hypertrophy of the tonsil disappears 
after puberty. In the meantime cases that are not properly 
treated may suffer permanent injury. Infection occurs more 
readily and diphtheria is more severe. 

Chronic tonsillitis — treatment : The tonsil should be re- 
moved, possibly best with a tonsillotome or in adults with 
a cold-wire snare. Hemorrhage is usually of short duration 
in infants ; but in adults may be severe and require torsion, 
pressure, or possibly even ligation of the common carotid. 
Usually such hemorrhage may be avoided by the use of the 
cold-wire snare. 

DISEASES OF THE PHARYNX. 

ACUTE PHARYNGITIS. 

Etiology : Acute pharyngitis is frequently ascribed to 
^'taking cold." Probably the most frequent causes are im- 
pure air, loss of sleep, and fatigue. The disease is frequently 
observed in connection with diseases of the stomach. Ob- 
struction of the nose is an important etiological factor in 
many cases. 

Symptomatology: There are tickling in the throat, a dry 
cough, and a persistent desire to swallow. Inspection reveals 



RETROPHARYNGEAL ABSCESS. 



179 



the mucous membrane of the pharynx reddened, possibly 
streaked with secretion from the naso-pharynx. Dysphagia 
would indicate involvement of the tonsils. The constitu- 
tional symptoms are not so marked as in tonsillitis. The 
attacks usually last from three to six days. 

In diagnosis the ditferentiation from diphtheria is most im- 
portant. All doubtful cases should be examined bacteriologi- 
cal ly. 

Acute pharyngitis — treatment : Symptomatic. Inhalations 
of steam, simple or medicated, and hot gargles give most 
relief. Any underlying disease on the part of the stomach 
or nose should be remedied. Fever may call for quinine or 
phenacetin. 

CHRONIC FOLLICULAR PHARYNGITIS. 

Chronic follicular pharyngitis usually begins in childhood, 
when the disease is frequently overshadowed by enlargement 
of the tonsils. Excessive use of the voice probably plays a 
role in etiology. 

Symptomatology : Often there are dull pain and tickling in 
the throat, hoarseness, dry cough, and hawking. Examina- 
tion reveals the hypertrophied pharyngeal lymph-follicles, 
bright red in color, and sometimes redness of the entire 
pharynx. There will not be increased secretion, nor will 
the uvula be elongated, unless there is a complicating naso- 
pharyngeal catarrh. 

Prognosis : The disease is chronic but not serious. 

Treatment: Excessive use of the voice should be avoided, 
and the patient should be placed under good hygienic sur- 
roundings. Further than this the treatment is surgical. The 
hypertrophied follicles should be removed, best by the cautery, 
actual or galvanic. 

RETROPHARYNGEAL ABSCESS. 
Etiology: Most cases occur in infancy. Traumatism has 
been given as a cause. Sometimes the disease follows the 
exanthemata. Some cases are undoubtedly due to vertebral 
caries (tuberculosis) ; in other cases streptococci are found. 



180 DISEASES OF THE ORGANS OF DIGESTION. 



Symptomatology : Dysphagia may cause the infant to refuse 
to nurse. There are cough, slight fever ; later dyspnoea and 
cyanosis. There is a peculiar audible ins})iration. In adults 
there are pain, dysphagia, fever, chills, and dyspnoea. There 
is bulging upon one side, and palpation will reveal the pres- 
ence of pus. In adults there is more inflammatory reaction 
than in children. 

Diagnosis : Retropharyngeal abscess should be differentiated 
especially from croup or oedema of the glottis in children by 
physical examination ; and from aneurism and tumors in 
adults. 

Prognosis : Except when due to tuberculosis, the disease 
usually lasts two to four weeks in children, and in adults runs 
a course similar to suppurative tonsillitis. Death may be 
caused by suffocation, erosion of a bloodvessel, rupture into 
the trachea or oesophagus, septicaemia, or by oedema of the 
glottis. Sudden death has been attributed to pressure on the 
large cervical nerves or ganglia. 

Retropharyngeal abscess — treatment : Scarification may be 
practised before there is suppuration. The presence of pus 
demands its evacuation. Cases due to tubercular caries of 
the vertebrae are more chronic. It has been recommended 
that such abscesses should not be opened unless there is 
danger from some complication or suffocation. When due 
to tuberculosis, the use of tuberculin and the general treat- 
ment of tuberculosis is indicated. 

DISEASES OF THE SALIVARY GLANDS. 

Mumps has been described under the Infections. 

The salivary glands may be involved in a suppurative 
process, to constitute secondary parotitis, symptomatic paro- 
titis, or parotid bubo. 

The secretion of the salivary glands may be lessened or 
stopped entirely, constituting the condition known as xero- 
stomia or dry mouth. 

Or the secretion of the glands may be increased, to con- 
stitute ptyalism or salivation. The cMej" causes of increased 
secretion of the salivary glands are pregnancy, certain drugs, 



DISEASES OF THE (ESOPHAGUS 



181 



especially pilocarpine mercury, iodide of potassium, jaborandi, 
muscarin, :ind tobacco; certain metals, especially gold, silver, 
copper, arsenic, and lead ; lesions of the pons and medulla ; 
certain infective diseases, especially hydrophobia and smallpox ; 
and some psychic disturbances, especially insanity, hysteria, 
and the perception of certain tastes. 

DISEASES OF THE OESOPHAGUS. 

GENERAL CONSIDERATIONS. 

The diseases : The oesophagus, though freely open to insult, 
is comparatively rarely the seat of disease. Probably one of 
the most common affections of the oesophagus is spasm of the 
cesophagiiSy oesophagisraus, spasmodic dysphagia, angina con- 
vulsiva, or spasmodic stricture of the oesophagus. Paralysis, 
hypersesthesia, and ansesthesia of the oesophagus are sometimes 
encountered. The oesophagus may be aflPected by organic 
stricture, carcinoma, dilatation, the formation of a diverticu- 
lum, the presence of acute or chronic inflammation or foreign 
bodies. Perforation and rupture of the oesophagus may occur. 
Other conditions are ulcer of the oesophagus, hemorrhage, 
tuberculosis, syphilis, parasitic disease, and congenital defects 
and malformations. 

Inspection may reveal a swelling upon the left side of the 
neck, due to a diverticulum or tumor of the oesophagus. 

Such a revelation may be confirmed by palpation, especially 
when made while the sound is in the oesophagus. 

Auscultation may help in the diagnosis of obstruction, espe- 
cially of the lower end of the oesophagus, since in such cases 
auscultation practised at the tenth rib upon the left of the 
spine, or upon the left of the ensiform cartilage, may not dis- 
close the sound produced by the entrance of the bolus of food 
into the stomach from the oesophagus, which normally occurs 
about six seconds after swallowing (Meltzer). 

Of more practical value is the use of the sound, with which 
we may measure the calibre of the oesophagus, detect and 
locate strictures and dilatations and sensitive or ulcerated 
spots as well as foreign bodies. A stomach-tube with a closed 



182 



DISEASES OF THE ORGANS OF DIGESTION. 



end may be used as a sound. The chief contraindication to 
the use of the sound is the presence of an aortic aneurism. 

Further examination of the oesophagus may be made by 
means of the cesophagoscope, which is rendered more practica- 
ble, under cocaine anaesthesia, since the improvements in the 
electric light. Through the cesophagoscope scars may be seen 
and portions of suspicious growths removed for microscopic 
examination. The character of the membrane may also be 
studied as to the presence of acute or chronic inflammation, 
and dilatation may be readily recognized (Rosenheim). For- 
eign bodies, which otherwise may not be removable without 
the intervention of surgery, may sometimes be withdrawn 
through an oesophageal tube (Von Hacker). 

The Rontgen ray is frequently used for the detection of 
foreign bodies in the oesophagus. 

OBSTRUCTION OF THE (ESOPHAGUS. 

Obstruction may be due to strictures, muscular spasm, foreign 
bodies, tumors, external compression, and congenital stenosis. 

Strictures may be caused by caustics, syphilis, ulcer, and 
cancer. Stricture of the oesophagus is to be differentiated 
from muscular spasm, best by means of the sound. 

Foreign bodies usually have a distinct history. 

Obstruction of the lumen of the oesophagus may also be 
caused by a growth of the thrush fungus along the oesopha- 
geal wall in individuals greatly debilitated. 

Tumors, polypi, and cancers may cause obstruction by grow- 
ing into the lumen of the oesophagus. 

External compression of the oesophagus may be caused by 
prevertebral abscesses and tumors, enlarged cervical and 
mediastinal lymphatic glands, tumors of the mediastinum and 
thyroid gland, aneurism, and possibly by a distended diver- 
ticulum. 

Congenital stenosis is rare, and may be suspected in infancy 
when the symptoms of obstruction come on without any other 
apparent cause. 

The prognosis is good, at least so far as life is concerned, in 
obstruction of the oesophagus due to muscular spasm. Cica- 



DIVERTICULUM OF THE (ESOPHAGUS. 



183 



tricial strictures which permit the introduction of the sound 
may be kept open by the occasional passage of this instru- 
ment. Strictures which do not permit the passage of the 
sound may cause death through marasmus. Foreign bodies 
may be remoyed. The outlook in cancer and aneurism is bad. 

Treatment : Foreign bodies should be remoyed as soon as 
possible. Strictures require long-continued gradual dilatation. 
External and internal oesophagotomy haye been successful. 
In cases of obstruction from cancer, careful dilatation secures 
temporary relief. 

DILATATION OF THE (ESOPHAGUS. 

Dilatation may be caused by obstruction of the cesophagus, 
the dilatation appearing aboye the obstruction. Other cases 
may be due to a weakening of the muscular wall. Some 
cases, especially those occurring in early infancy, seem to 
indicate that the condition may be congenital. 

The chief symptoms are those referable to the retention of 
food in the oesophagus. There is dulness to the right of the 
spine after the ingestion of food ; with later regurgitation and 
yomiting 

Diagnosis may sometimes be made clear by the introduction 
of the sound. 

DIVERTICULUM OF THE (ESOPHAGUS. 

A circumscribed dilatation of the wall of the oesophagus 
may occur, especially in males, at or before middle life. Zenker 
and y. Ziemssen belieye the condition to be a hernia of the 
mucous membrane through the muscular coat, weakened by 
trauma, ulcer, or scar. Some obseryers belieye the condition 
to be congenital. 

Symptoms : Food, which sooner or later must be liquid, 
may be regurgitated, sometimes to reach the stomach upon 
being reswallowed. Hegurgifafion may be aided by pressure 
on the left side of the neck. There is often emaciation. 
Cases haye been found post mortem without symptoms during 
life. 

Diagnosis can usually be made with the sound. 



184 



DISEASES OF THE ORGANS OF DIGESTION. 



Treatment of the diverticulum may be unnecessary. Other 
cases call for the use of the sound. Extirpation has been 
successfully performed in several instances (v. BergmanUj 
Kocher, Butlin, Mixter). 

PERFORATION AND RUPTURE OF THE (ESOPHAGUS. 

The oesophagus may suffer perforation from foreign bodies, 
instruments, ulcers ; or secondarily, from aneurism, retro- 
pharyngeal abscess, tuberculosis of the vertebrae or peri- 
bronchial glands, rarely from tuberculosis pulmonum. 

The first symptom may be pain during swallowing or 
coughing, sometimes followed by the vomiting of pus (ab- 
scess) or of food. The temperature is high and irregular. 
There is pain upon swallowing. Perforation of a bronchus 
or of the trachea causes a sudden paroxysmal cough and the 
ejection of food through the larynx. Later there is severe 
bronchitis, possibly gangrene and abscess of the lung. 

Among the complications that may occur are pleurisy, peri- 
carditis, pneumothorax, pyopneumothorax, and pneumoperi- 
cardium. 

The prognosis assumes gravity with the severity of the 
symptoms. 

Treatment is symptomatic. Nourishment may be supplied by 
enemata. Complications, if possible, should be met by surgery. 

Rupture of the oesophagus is of rare occurrence. The rupt- 
ure occurs longitudinally in the front or side of the esophagus, 
between the bifurcation of the trachea and the diaphragm. 
There is the history of violent vomiting or efforts to expel a 
foreign body from the oesophagus. There may be little pain 
attending the rupture. Later there occur emphysema, pleu- 
risy, and death as a rule within three days, although life may 
be prolonged a week. 

Hemorrhage from the oesophagus may be profuse, from rupt- 
ure of an aneurism, varicose veins, or from the presence of a 
foreign body ; or the hemorrhage may be slight, from ulcer or 
cancer. Differentiation from gastric hemorrhage is sometimes 
difficult. Usually hemorrhage from the oesophagus occurs 
with regurgitation rather than vomiting. The treatment is 



INFLAMMATIONS OF THE (ESOPHAGUS. 



185 



symptomatic. If possible any cause, such as a foreign body, 
should be removed. Ice may be swallowed. Food may be 
given by enemata. Tannin, gallic acid, and iron are recom- 
mended. 

INFLAMMATIONS OF THE (ESOPHAGUS. 

CEsophagitis : Inflammation of the oesophagus may be caused 
by strong alcoholic beverages, corrosive fluids, hot food or 
drink, foreign bodies, food retained in the oesophagus by 
obstruction, infectious diseases, especially typhoid fever, scar- 
latina, variola, tuberculosis, and syphilis; by the extension of 
inflammation from contiguous structures, and chronic passive 
congestion due to cardiac obstruction. 

The chief symptoms are pain on swallowing and regurgita- 
tion. Mild cases may show no suggestive symptoms. In 
severe cases there may be fever, chills, and extreme prostra- 
tion. 

The diagnosis in the presence of dysphagia and regurgitation 
is easy. 

Prognosis : Cases of acute catarrh of the oesophagus recover 
rapidly ; cases of chronic catarrh usually show exacerbations 
and remissions over a long period of time. The prognosis is 
doubtful in corrosive and suppurative cases because of the 
tendency to perforation, the formation of fistulse, gangrene, 
and stricture. 

Treatment : Nourishment may be given per rectum. Ice 
and cold drinks may be taken internally. Cases caused by 
acids may receive alkalies, lime-water, or magnesia, to neu- 
tralize the acid. Where the cause has been an alkali, dilute 
acetic acid may be given. Toxic cases are relieved by wash- 
ing out the stomach, if there be no danger of tearing the oesoph- 
agus. Abscesses demand evacuation. The sound- or stomach- 
tube may be used in cases of chronic oesophagitis, to prevent the 
formation of a stricture. Pain may call for morphine or 
cocaine. 

Tuberculosis of the oesophagus is rare. The treatment, fur- 
ther than the use of tuberculin, is symptomatic. 



186 



DISEASES OF THE ORGANS OF DIGESTION. 



Syphilis of the oesophagus demands general syphilitic treat- 
ment (see Syphilis). Strictures should be treated mechani- 
cally, probably best by the passage of the sound. 

TUMORS OF THE (ESOPHAGUS. 

Tumors, except carcinomata, are rare. 

Carcinoma of the oesophagus is not infrequently encountered. 
As a rule the cancer is primary. Secondary deposits may 
occur from cancer of the stomach, more rarely of the pharynx 
or of the thyroid. About three-fourths of the cases occur in 
males, usually after forty. It has been observed that drunk- 
ards are most frequently affected. 

Diagnosis : Evidence of obstruction of the oesophagus, with 
gradually progressing symptoms, especially in a man past 
forty, should lead to the suspicion of carcinoma of the oesoph- 
agus. About nine-tenths of the cases of obstruction of 
the oes(^phagus after forty are due to carcinoma. Syphilis 
may be eliminated by the therapeutic test, if necessary. 
Pieces may be removed through the oesophagoscope and ex- 
amined microscopically to make the diagnosis absolute. Some- 
times a piece of the tumor, sufficient for microscopic examina- 
tion, may be discharged by vomiting, or may be removed with 
the stomach-tube or sound. 

Prognosis : The usual duration of life is ten to fifteen 
months. 

Treatment : Gastrostomy offers relief in some cases. 

(ESOPHAGISM. 

Spasm of the oesophagus occurs most frequently in women, 
especially in the neurasthenic, hysterical, and hypochondriacal. 
There are all degrees of dysphagia, and the condition may be 
of short or long duration, sometimes with intermissions. The 
diagnosis is readily made with the sound. The prognosis de- 
pends upon the underlying condition. 

Treatment : Any local or exciting cause should be removed. 
The use of the sound is usually the best method of treatment. 
Attention should be directed to the treatment of the under- 
lying disease — neurasthenia, hysteria, or hypochondriasis. 



ACUTE GASTRIC CATARRH. 



187 



Angina Ludovici is an acute septic inflammation of the throat, 
occurring chiefly secondary to the infections, especially diph- 
theria and scarlet fever, and sometimes caused by trauma. 
The infectious agent is usually a streptococcus. The sub- 
maxillary gland on one side is often first afl^ected. 

Treatment should be surgical and thorough. 

DISEASES OF THE STOMACH. 

ACUTE GASTRIC CATARRH. 

Etiology : Acute gastric catarrh is usually due to errors or 
indiscretions in diet, the use of hot or cold drinks, highly 
seasoned or fermented foods, insuflicient mastication of the 
food, the ingestion of alcohol and decomposed food, septicaemia, 
and toxaemia. The disease may be caused by a number of 
toxic substances : alcohol, phosphorus, arsenic, potassium 
cyanide, corrosive sublimate, potassium chlorate, concentrated 
acids, and caustic alkalies. 

Symptomatology : Heaviness at the pit of the stomach, later 
fulness and eructations, constitute the symptoms of the mild 
form of acute gastric catarrh. Severer cases may show in 
addition nausea, pain in the region of the stomach, headache, 
fever, vomiting, anorexia, and constipation or diarrhoea. Tlie 
stomach may be tender and bloated. The tongue is coated. 
There may be affection of the gall-bladder and icterus. In 
cases of phlegmonous gastritis, the pain in the region of the 
stomach is severe, with or w^ithout preceding dyspeptic symp- 
toms. The symptoms increase in severity. The fever is high, 
103°-105° F. Retching and vomiting of mucus and bile are 
common. The gastric region is tender to pressure. There is 
diarrhoea, sometimes constipation. 

Toxic cases show symptoms more or less severe according to 
the cause. There is gastric pain, which becomes more severe 
upon pressure. There is vomiting, sometimes hsematemesis. 
There is always thirst. There may develop peritonitis, icterus, 
and h?ematuria. In severe cases the pulse is weak and there 
may be cyanosis, cold perspiration, slight coma, possibly col- 
lapse and death. 



188 DISEASES OF THE ORGANS OF DIGESTION. 



Diagnosis : The history is often of value, since there may be 
revealed the ingestion of improper food or poisons. An ex- 
amination of the contents of the stomach may show a decrease 
in the amount of the gastric secretions, or the presence of 
poison in toxic cases. 

The diagnosis of phlegmonous cases is sometimes difficult or 
impossible during life. Such cases should be suspected when, 
in addition to the symptoms mentioned, there are increased 
resistance in the gastric region and great tenderness upon 
pressure. 

Toxic cases sometimes show affection of the mouth, tongue, 
or pharynx, due to the ingestion of corrosive or caustic poisons. 
Such cases may be cleared up sometimes by the history, or 
positively by the use of the stomach-tube or the examination 
of vomited matter. 

Cases of gastric catarrh, accompanied by fever, should be 
carefully differentiated from the infectious diseases, which 
often show an early catarrh. 

The differentiation between gastric catarrh and typhoid fever 
may be made by the usual sudden onset of the fever in gastric 
catarrh and the gradual onset of typhoid fever. Herpes is 
found especially in gastric catarrh ; a positive diazo reaction is 
found in the urine of typhoid fever, and the blood presents 
the Widal reaction. 

The pain from biliary calculi, as a rule, should not be mis- 
taken for gastric catarrh. 

Prognosis : As a rule, the prognosis of simple acute gastric 
catarrh is favorable. The aged and invalids may suffer 
serious complications. Phlegmonous cases have a worse out- 
look, death usually occurring within a week. Some cases 
may survive two weeks. Cases of so-called gastric abscess 
may run a chronic course. In the toxic cases the prognosis 
is doubtful, depending upon the nature and quantity of the 
poison taken and the condition of the patient when the case 
comes under treatment. 

Acute gastric catarrh — treatment : The stomach should be 
emptied. This may be accomplished by the use of emetics, 
best apomorphine hydrochlorate, or in children tartar emetic 
and ipecac. A better means is the use of the stomach-tube, 



CHRONIC GASTRIC CATARRH. 



189 



with which the stomach may be emptied and thoroughly 
washed. For a day or two the patient should receive only a 
light diet — strained gruels and weak tea. The diet may then 
be gradually increased by the addition of rice, soups, soft- 
boiled egg; later bread and butter and oysters, until the 
normal diet is reached. Meat once a day is allowed on the 
fourth day, if improvement is continuous. Constipation may 
be relieved by calomel, especially when there is fever, or by 
seidlitz powders or citrate of magnesium. 

In phlegmonous cases the treatment is symptomatic. Ice- 
bags are applied to the abdomen, and opium may be given in 
large doses, or morphine subcutaneously. Collapse calls for 
the use of the analeptics, camphor, ether, etc. 

In toxic cases the treatment varies with the nature of the 
poison. Strong acids or alkalies should be diluted and neu- 
tralized, the former with calcined magnesia and milk, 100 gm. 
to the pint ; the latter with lemonade or a 1 per cent, or 2 per 
cent, solution of acetic acid. As a rule, the use of the stomach- 
tube renders the use of antidotes superfluous. In some cases 
it may not be safe to use the stomach-tube for fear of perfora- 
tion of the stomach ; nor should vomiting be induced, on ac- 
count of the damage these substances may cause upon again 
coming in contact with the oesophagus and mouth when 
ejected. In toxic cases caused by the alkaloids and metals 
the use of the stomach-tube is the best treatment. In emer- 
gencies emetics may be employed. 

Complications call for appropriate treatment. 

CHRONIC GASTRIC CATARRH. 

Etiology : The chief causes are : improper food, ice- water, 
and highly-seasoned food ; rapid eating, whereby the food is 
not properly masticated ; sore mouth and bad teeth, which 
may cause trouble also through the swallowing of the products 
of decomposition ; the ingestion of too large quantities of 
food, the excessive use of tobacco, chewing or smoking ; the 
drinking of tea and coflPee, and alcoholic beverages, especially 
the stronger ones, and the use of so-called " stomach bitters." 

Chronic gastric catarrh may follow repeated attacks of acute 



190 DISEASES OF THE ORGANS OF DIGESTION. 



gastric catarrh, or date its origin from an attack of some severe 
infection, such as typhoid fever. Some cases are secondary to 
certain diseases, such as gout, diabetes, and chronic diseases 
of the lungs, heart, liver, and kidneys. 

Chronic gastric catarrh — symptomatology : The onset is in- 
sidious. There are a bad taste in the mouth, poor appetite, 
a feeling of fulness and oppression after meals, sometimes pal- 
pitation and shortness of breath, and possibly dizziness, which 
may compel the patient to seek the recumbent posture. Belch- 
ing is frequent ; and often there are regurgitation, sometimes 
nausea, less frequently vomiting. Constipation is the rule ; or 
there may be diarrhoea, and in some cases constipation and 
diarrhoea alternate. The urine is scanty and frequently con- 
tains phosphates and urates. There are languor, lack of energy, 
often headache, in some cases persistent yawning and inability 
to breathe deeply. There may or may not be loss of weight. 
The tongue is coated and indented by the teeth. The gastric 
region is bloated and tender upon pressure. 

Diagnosis : The gradual onset and chronic course of the 
disease, with the symptoms enumerated, should lead one 
strongly to suspect chronic gastric catarrh. The diagnosis 
may be confirmed by an examination of the contents of the 
stomacli. The patient may be given the test-breakfast of 
Ewald, consisting of an ordinary roll or piece of white bread 
without butter, and a large cup of tea without sugar or milk. 
The stomach-contents are withdrawn one hour later. The 
quantity of the contents will vary from 120 to 180 c.c, and the 
roll will not be found reduced to as fine particles as when di- 
gestion is normal. Mucus is present in great quantities in 
some cases, and absent in others. In the presence of mucus, 
acetic acid produces turbidity when added to tlie filtrate. 
Free hydrochloric acid is altogether absent or present in only 
small quantities. Pepsin and rennet may be found. There 
are small quantities of erythrodextrin, and an abundance of 
achroodextrin and sugar. The absorptive power of the 
stomach does not necessarily present any considerable altera- 
tion from normal. 

The differential diagnosis concerns chiefly cancer, the neu- 
roses, and achylia gastrica. Pain, haematemesis, and marked 



CHROSIC GASTRIC CATARRH. 



191 



emaciation are absent in chronic gastric catarrh, and present 
in nicer and cancer. The gastric neuroses may be recognized 
by the presence of other nervous symptoms. The -ymptoms 
and stomach-contents show less variation in chronic gastric 
catarrh than in tlie gastric neuroses. Achylia gastrica shows 
not only absence of hydnjchloric acid, but also absence of 
rennet and pepsin. 

Prognosis : Good, btit recovery is tedious. Recurrences 
mav be caused by indiscretions in diet. 

Clironic gastric catarrh — treatment : The diet should be reg- 
ulated, and at hrst light, consisting chiefly of milk, kumyss^ 
matzoon, soups of barley, oatnreal and rice in milk, chicken 
soup, Avhich may contain an egg, soft-boiled eggs, mashed 
potatoes, scraped meat, toast ; later bread and butter, tea and 
cocoa. The patient should avoid meat that is tough, too fresh 
or too fat, especially pork, sausages, and lobster, salmon, 
chicken .sahtd, mayonnaise, cucumbers, pickles, cabbage, and 
alcoholic beverages. The meals must be eaten slowly and the 
food thoroughly masticated. 

The patient should observe regular hours and exercise espe- 
cially in the open air, walking, driving, riding, rowing. Ten 
minutes' gymnastics may be taken every morning, followed 
by a cold sponge-bath and thorough rubbing. Ventilation 
with pure air is important. 

Further than the regidation of the diet and lu'ihifs. most 
may be accomplished by lavage. The stomach sliould be 
washed out before breakfast every other day for two or three 
weeks. 

Electrieitii may be used, a large sponge-electrode placed 
over the gastric region and a smaller electrode upon the back, 
about the level of the seventh vertebra, on the left of the 
spine. A better method is the erii|)L )yment of intragastric 
electrization by means of a deglutable -tomach electrode (Ein- 
horn), using the fliradic current. Such treatment should be 
continued two or three months. 

Certain minprat irnttrs are excellent therapeutic agents in 
chronic gastric catarrh, and are best taken at the springs, 
since there the patient is placed under the best hygienic sur- 
roundings. A tumblerful is taken upon arising. As a rule, 



192 DISEASES OF THE ORGANS OF DIGESTION. 



the saline waters, containing sodium chloride with varying 
amounts of carbonic acid gas, are to be preferred. In cases 
of marked constipation, waters containing sodium sulphate, 
sodium carbonate, and sodium chloride, with large amounts 
of carbonic acid gas, are useful. 

Of drugs, hydrochloric acid is especially indicated by its 
dehciency in the gastric juice. Ewald recommends gtt. xl-lx 
of dilute hydrochloric acid three times a day. Einhorn gives 
smaller doses, gtt. vj~xij, of dilute hydrochloric acid in a 
glassful of water half an hour after meals, taken " one-third 
at a time at intervals of a quarter or half an hour." Pepsin 
is rarely useful. Of more value are the bitter tonics, con- 
durango, quassia, gentian, kino, columba, and nux vomica, 
taken fifteen minutes before meals in a wineglass of water. 
Creosote is of value in the gastritis of phthisis. 

Constipation may be relieved largely by regular habits of 
going to the closet. The ingestion of coarse foods increases 
the quantity of faeces and peristalsis. Thus rye bread and 
green vegetables, sucli as spinach, asparagus, and green peas, 
are useful. The diet may also include fruits, cooked pears, 
stewed or baked apples, and stewed prunes. A good com- 
bination is two parts of prunes and one part of dried figs 
(Ewald). An orange may be eaten in the morning. A glass 
of water or milk may be taken upon arising. In some cases 
rhubarb or cascara sagrada will be found useful. Severe con- 
stipation calls for aloes and podophyllin. Einhorn recom- 
mends : 

^. Podopliyllin, gr. v (0.3) ; 

Ext. nucis vomic^e, 

Ext. calabar bean, dd gr. viiss (0.5) ; 

Ext. gentian., 

Ext. pulv. glycvrrh., dd q. s. 
M. et ft. piL No. 30. 
S. One pill twice a day. 

Enemata are useful, especially in cases of atony or weak- 
ness of the large intestine. For an enema there may be used 
one quart of lukewarm water, containing a teaspoonful of 



GASTRIC ULCER. 



193 



common salt. The injections should be given daily, always 
at the same time, for two weeks. Glycerin suppositories 
or injections of glycerin in water, a teaspoouful to four or five 
tablespoonfuls of water, are sometimes useful. 



GASTRIC ULCER. 

Etiology : Ulcer of the stomach is found in 6 per cent, of 
post-mortems, about twice as frequently in women as in men 
(Brinton) ; most often between twenty and forty years of age 
(Ewald). 

The cause is unknown ; but many theories have been for- 
mulated, some of which have been more or less generally ac- 
cepted. 

V. Sohlern, who found the inhabitants of certain parts of 
Germany and Russia practically exempt from the disease, 
attributed this fact to an exclusive vegetable diet and recom- 
mended such a diet and the administration of some of the 
salts in prophylaxis. 

It has been frequently asserted, but not without contradic- 
tion (Ewald), that ulcer of the stomach is especially frequent 
in certain vocations (shoemakers). 

Experimental mjuries of the gastric mucous membrane in 
animals heal readily (Griffini and Vassale), except w hen there 
is some alteration in the bloocJ, anaemia (Quincke and Daett- 
wyler) ; hsemoglobingemia (Silbermann). Gastric ulcer is 
especially frequent in chlorotic patients. 

The introduction of dilute hydrochloric acid into the 
stomach (0.5 per cent, solution), after the production of gastric 
hemorrhage by section of the spinal cord, caused the forma- 
tion of deep ulcers (Koch and Ewald). 

The formation of gastric ulcer has been attributed to the 
destruction of an infarct caused by an embolus or thrombus 
(Virchow), and ulcer has been produced in this way experi- 
mentally by Panum. We are not always able to find an em- 
bolus or thrombus in cases of gastric ulcer. 

Pavy attributed the formation of ulcer of the stomach to a 
diminished alkalinity of the blood permitting the tissue to be 
attacked by the gastric juice. It is now believed that hyper- 

13— P. M. 



194 DISEASES OF THE ORGANS OF DIGESTION. 



acidity of the gastric juice plays an important role in the 
etiology of gastric ulcer. Chlorosis, anaemia, and amenorrhcea 
are frequently associated with ulcer of the stomach, and in 
these conditions there is, as a rule, hyperacidity of the gastric 
juice. At any rate, it is well known that hyperacidity of the 
gastric juice is usually found in cases of ulcer of the stomach; 
but Einhorn has observed ulcer of the stomach in cases show- 
ing an ''entire absence of gastric juice." 

Gastric ulcer — symptomatology : There is early disturbance 
of digestion; at first epigastric uneasiness and pain; later, 
nausea, regurgitation, and vomiting. There may be hemor- 
rhage. The disturbances of digestion and hemorrhage cause 
anaemia and cachexia. 

As a rule, pai7i comes on in from two to ten minutes after the 
ingestion of food, and continues as long as there is food in the 
stomach. Exceptionally pain appears only half an hour to 
two or three hours after the ingestion of food. Pain is in- 
creased especially by coarse and indigestible food, and is more 
likely to be severe after a large meal. The pain or tender- 
ness in the epigastrium is circumscribed. After a few weeks 
or months pain appears in the dorsal region, usually to the 
left of the eighth or ninth dorsal vertebra. Hemorrhage may 
be revealed by haeniatemesis or mehena ; or in very severe 
cases the blood may not escape before death and be found in 
the stomach upon autopsy. Small hemorrhages may be 
detected only upon microscopic or chemic examination of the 
stomach-contents. The appetite is good; but patients may 
refuse to eat for fear of pain. 

Diagnosis : Cases of ulcer of the stomach often show hyper- 
chlorhydria. Useful points in diagnosis are the age and sex 
of the patient; the localization, character, and time of occur- 
rence of pain; the appetite, regurgitation, and vomiting; the 
increased quantity of gastric juice, absence of lactic acid, and, 
as a rule, increase of hydrochloric acid ; hsematemesis, perfora- 
tion, and anaemia. Some idea as to the location of the ulcer 
may be obtained from the position assumed by the patient 
for the relief of pain, since most comfort will probably be 
experienced when the ulcer is brought least in contact with 
the gastric juice. 



GASTRIC ULCER. 



195 



Ulcer of the stomach should be differentiated especially 
from gastralgia, hyjjerchlorhydria, and gastric carcinoma. 

Prognosis should be guarded. The outlook is better in 
cases that come under treatment early. 

Gastric ulcer — treatment : Rest in bed should be observed 
for two or three weeks. Milk is the best food, to which may 
be added barley-water, oatmeal-water, rice-water, plain water, 
weak tea, peptone, meat-powder, and lactose. During the first 
week the patient should receive half a glassful of milk every 
hour. During the second week the quantity is increased to a 
glassful and a half every two hours, and the patient may re- 
ceive once or twice a day a raw egg beaten up in the milk. The 
third week the patient may receive, in addition, barley, farina, 
rice, soft-boiled eggs, and crackers and milk, every three hours. 
During the latter half of the third week meat may be added, 
at first raw scraped meat, later broiled. Gradually the reg- 
ular diet is resumed. During the third week the patient may 
get up, at first for a short time only, and may go out of doors 
the fourth week and gradually resimie the ordinary daily 
routine of life. During the first two weeks warm flaxseed 
poultices may be applied over the region of the stomach dur- 
ing the day, and a wet linen cloth at night. 

Severe pain, vomiting, or hsematemesis may necessitate 
rectal alimentation. In the morning the intestine should be 
washed out, bestv/ith a quart of water containing a teaspoonful 
of common salt. An hour later an ensema may be given con- 
sisting of one or two raw eggs beaten up in a glass of milk, to 
which a pinch of salt is added ; or a teaspoonful of peptone in 
a cup of water. The enema should be given at a temperature 
of about 100° F., and repeated three or four times a day. 
This may be continued five days, when food may usually be 
given per os. 

Pain may be relieved by codeine. Constipation is controlled 
by Carlsbad salt. Hyperacidity of the gastric juice may be 
relieved by : 



196 DISEASES OF THE ORGANS OF DIGESTION. 



'B^. Magnesise ustse, 3j (5.0) ; 

Sodii carbonatis, 
Sodii bicarbonatis, 

Elseosacch. menth. pip., da (15.0). 
M. exactissime, f. pulv. 

S. As much as will rest on the point of a knife, 
every two hours. (Einhorn). 

Patients who cannot remain in bed may receive nitrate of 
silver, 0.3-0.6 : 180.0 water, a tablespoonful in a wineglassful 
of water half an hour before meals. Or subnitrate of bismuth 
may be used, 3.0-5.0 in a wineglassful of water, half an hour 
before meals. Such treatment should be continued tAvo or 
three weeks. 

Hemorrhage is met by the application of an ice-bag over 
the region of the stomach and absolute rest in bed. In severe 
cases ergot may be given subcutaneously, or the stomach may 
be carefully washed out with ice-cold water (Ewald), best 
after the application of cocaine to the pharynx to prevent ex- 
cessive retching. 

For GoUcqjse, the analeptics, best camphor and ether, may 
be used subcutaneously. A hot-water bag should be placed 
at the feet, and there may be given an enema of warm wine, 
to which an egg may be added. Often salt-water infusion is 
of the greatest value. 

Perforation demands absolute rest and abstinence from food 
and drink, the use of the ice-bag over the stomach, and of 
opium, best in suppositories. Should there be a large quantity 
of food in the stomach, it may be carefully removed with a 
stomach-tube. Laparotomy and suture have been successful 
in some cases. 

GASTRIC CARCINOMA (Carcinoma Ventriculi; Cancer of the 

Stomach). 

Etiology: No specific infectious agent has been isolated. 
Carcinoma is believed by PfeifPer to be due to a variety of 
the sporozoa. The stomach, with the possible exception of the 
uterus, is the most frequent seat of cancer, about one-fourth 



GASTEIC CARCINOMA. 



197 



of all cases of cancer occurring in the stomach. The occur- 
rence of the disease seems on the increase. The age of 
greatest liability is forty to sixty years. But congenital cases 
have been reported (Wilkinson and Wiederhoefer). Sex seems 
to exert little or no influence. Heredity in some cases seems 
to play a role in etiology. Trauma, mental worry and anxiety, 
and indulp^ence in cider and sour wines have been considered 
causes. 

The chief varieties, in the order of frequency, are: scirrhous, 
medullary, colloid, melanotic, and epithelial carcinoma. 

Cancer of the stomach — symptomatology : Usually there is 
anorexia ; in 85 per cent, of cases (Brinton). There may be 
an aversion for certain foods, especially meat and albuminous 
food, and a craving for highly-seasoned food, pickles, herring, 
etc. Pain is present in almost all cases, and is more or less 
constant, frequently of a lancinating character, sometimes dull, 
gnawing, burning. There may be tenderness upon pressure. 
The ingestion of food causes little if any increase of pain, 
and there is no relief aflbrded by vomiting. Vomiting occurs 
in perhaps even more cases than anorexia, oftener when the 
carcinoma is at the pyloric or cardiac extremity of the stomach 
than when situated elsewhere. Hsematemesis is present in 
many cases, sometimes melfena. 

A tumor, usually hard, irregular, nodulated, sometimes 
smooth and small, may be revealed by gastrodiaphanoscopy 
sometimes before the diagnosis can be made by palpation. 
Most cases show cachexia. 

Examination of the blood reveals a reduction of red blood- 
corpuscles and haemoglobin, and an increase of leucocytes. 
Probably of more importance is the observation that the 
number of leucocytes is about the same at the height of diges- 
tion as during fasting (Schneyer). Normally the number is 
increased during digestion. 

The urine may contain more nitrogen than is introduced 
with the food (Klemperer, Miiller). Frequently there is a 
diminution of the chlorides ; occasionally there is peptonuria, 
indicative of absorption from some ulceration in the digestive 
tract. 

Carcinoma at the cardiac extremity of the stomach usually 



198 DISEASES OF THE ORGANS OF DIGESTION. 



causes dysphagia and may produce complete stenosis. The 
deglutition-sound, made by the bolus of food entering the 
stomach, may be absent or retarded, appearing sometimes 
twenty seconds, instead of seven seconds, after swallowing. 
Examination with the stomach-tube or sound may reveal more 
or less diminution of the calibre of the cardiac opening. Some- 
times particles of the tumor may be withdrawn through the 
stomach-tube. These should be examined microscopically. 
The constant presence of blood upon examination with the 
stomach-tube should raise the suspicion of cancer, probably 
situated at the cardiac extremity of the stomach. 

Carcinoma at the pyloric extremity of the stomach causes 
pain, a feeling of fulness, and vomiting of chyme and of food 
which may have been taken a day or two before. The tumor 
is usually to the right of the linea alba, between the umbilicus 
and ribs. 

Carcinoma of the stomach proper presents a constant gnaw- 
ing pain, marked cachexia, tumor to the left of the linea alba, 
vomiting of food, and the retention of chyme in small quan- 
tities. 

Diagnosis : The great majority of cases of cancer of the 
stomach occur after forty. Pain, usually not intense, is con- 
tinuous. The appetite is poor ; the tongue usually heavily 
coated. Eructations are the rule, the odor often being disa- 
greeable, sometimes foetid. There is pyrosis. Vomiting, 
often of large quantities, occurs once or twice a day or every 
other day. The gastric juice is usually greatly decreased in 
amount. The blood discharged by h^ematemesis is usually 
slight, as a rule coflPee-brown in color, often decomposed and 
foetid. 

Palpation will usually detect a tumor, movable, uneven, 
tender to pressure. Perforation occurs only late in the dis- 
ease. Cachexia is marked. 

The examination of the gastric juice reveals an absence of 
free hydrochloric acid and the presence of lactic acid. Rarely, 
free hydrochloric acid may be found in carcinoma, and lactic 
acid has been found in non-malignant cases. 

A microscopic examination of the particles withdrawn from 
the stomach may make the diagnosis absolutely positive. 



GASTRECTASIA. 



199 



The differential diagnosis has to do with idcer, benign steno- 
sis of the pylorus, chronic gastric catarrh, achvlia gastrica, 
severe gastric neurasthenia, and benign tumors. 

Prognosis : Death may occur within a month to two years, 
usually within a year, depending upon the situation and 
variety of the carcinoma and the complications that may 
arise. 

Cancer of stomach — treatment : Good temporary results 
have been reported from the use of the iodides, arsenic, 
condurango, and a great number of remedies. Pain may be 
relieved by opium, morphine, codeine (usually best given in 
combination with belladonna or atropine). Constipation is 
relieved by rhubarb, compound licorice powder, cascara 
sagrada, enemata, glycerin suppositories. Obstinate vomiting 
may be obviated by washing out the stomach occasionally or 
by the use of opiates. Hemorrhage, when considerable, may 
be treated as in cases of ulcer of the stomach. When there 
is decomposition of food or ulceration, chloral may be ad- 
vantageously given (Ewald, Einhorn). The patient should 
receive an abundance of such food as he can take and assimi- 
late. 

In the way of absolute cure, more hope is offered by sur- 
gery. Complete removal of the carcinoma, by resection of 
the pylorus, excision of the tumor, or even removal of the 
stomach, may be resorted to when the diagnosis is made early, 
before the tumor has attained a large size, and before met- 
astases have formed. Other contra-indications are great anae- 
mia or cachexia and extreme age. Gastrostomy in carcinoma 
of the cardia or oesophagus, and gastro-enterostomy in carci- 
noma of the pylorus, may be resorted to as palliative meas- 
ures. 

GASTRECTASIA. 

Gastrectasia, dilatation of the stomach, is caused most fre- 
quently by obstruction of the pylorus. Thus the condition 
occurs most frequently in carcinoma and from the cicatriza- 
tion of ulcers. Less frequently gastrectasia may be caused 
by paresis of the stomach-wall, the result of chronic catarrh 



200 DISEASES OF THE ORGANS OF DIGESTION. 



of the stomach. Sometimes the condition is due to fatty de- 
generation, extensive atheroma, or amyloid disease. Rarely 
there may be no apparent cause. 

Symptomatology : The stomach is increased in size, so that 
the fundus occupies the left hy})ochondrium, the pylorus ex- 
tends into the right hypochondrium, and the lower border of 
the stomach may be found below the umbilicus. The coudi- 
tion is frequently revealed by the large quantity of material 
discharged during the act of vomiting. Digestion is delayed, 
and the stomach-contents show evidence of decomposition, 
acetic and butyric fermentation, and the presence of sarcinse 
and various other micro-organisms. Nervous symptoms are 
common, especially depression of spirits and hypochondriasis. 
Sometimes there is coma. 

Prognosis: The outlook -depends upon the cause. Cases 
due to paresis depending upon catarrh of the stomach may 
recover. The prognosis is bad in carcinoma. 

Treatment : Most may be accomplished by lavage and diet, 
both in the cure and relief of the condition. Digestion may 
be aided by the use of dilute hydrochloric acid and the bitter 
tonics, especially the tincture of nux vomica. Faradization 
is often of value. Constipation may be relieved best by 
Carlsbad salts, the compound pill of rhubarb, or cascara 
sagrada. Carcinoma may justify an appeal to surgery. There 
are also cases of simple gastrectasia which have been benefited 
by placing a r^eef in the wall of the stomach (gastrorrhaphy). 

GASTROPTOSIS. 

Gastroptosis is a downward displacement of the stomach, 
frequently associated with displacement of other organs, espe- 
cially with enteroptosis, nephroptosis, and hepatoptosis. The 
prolapse of the abdominal viscera may become general, to 
constitute a s])lanchnoptosis. 

Symptoms : There are weakness, lassitude, sleeplessness, and 
constipation or irregularity of the bowels. The patient ex- 
periences difficulty in the digestion of fats, farinaceous foods, 
acids, pure wine, pure milk, with an increase in the digestive 
troubles about three hours after meals (Einhorn). Physical 



FUNCTIONAL BISTUEBANCES OF THE STOMACH. 201 



examination reveals decreased abdominal tension and prolapse 
of the abdominal organs. 

Diagnosis is best made by inflation of the stomach or the 
use of the gastrodiaphane. 

Treatment : The intestines and stomach should be raised 
and the aV)domen supported by a well-fitting abdominal band- 
age. Constipation must be corrected. Further treatment is 
symptomatic, and depends largely upon the result of the ex- 
amination of the contents of the stomach. The bowels should 
be regulated. Deficient secretion may be stimulated by mas- 
sage, electricity, and lavage. 

FUNCTIONAL BISTUEBANCES OF THE STOMACH. 

In hypercMorliydria the amount of acid and ferments, and 
sometimes the total amount of the gastric juice, are increased. 
There is usually pain two or three hours after meals, relieved 
especially by albuminous food and alkalies. The appetite 
may be increased above normal. As a rule, there is constipa- 
tion. 

Treatment, which is symptomatic, calls for the avoidance 
of mental work and regulation of the daily life. Acids and 
spices should be excluded from the diet, which should consist 
largely of albuminous food. After meals the patient must 
rest fifteen or twenty minutes. Alkalies are indicated. In 
the absence of constipation, bicarbonate of sodium and mag- 
nesia usta may be given. When there is constipation, Einhorn 
recommends : 

Magnesise ust^e, 

Pulv. rad. rhei, da 3ij (7.5). 

Sodii carbon, exsiccat., 
Sodii bicarbonatis, 

Elseosacch. menth. pip., dd ^iv (15.0). 
M. exactissime, f. pulv. D. ad scatuium. 
S. Half a teaspoon ful to a teaspoonful three times 

daily, two hours after meals, to be taken in 

plain water or Vichy water. 



202 DISEASES OF THE ORGANS OF DIGESTION. 



Gastrosuccorrhoea continua periodica is characterized by a 
periodic continuous flow of gastric juice, with vomiting and 
severe pain. 

Gastrosuccorhoea continua chronica shows a constant secretion 
of gastric juice even when the patient is fasting; and runs a 
chronic course. Cases of gastrosuccorrhoea always show hyper- 
chlorhydria. 

In the treatment, liquids must not be allowed in large quan- 
tities. Lavage is of value, either with plain water or with 
solutions of nitrate of silver, 300 c.c. of a 1 : 1000 or 2: 1000 
solution (Reichmann); or the stomacli may be sprayed with a 
similar solution of nitrate of silver (Einhorn). Einhorn also 
recommends direct galvanization of the stomach. Atropine, 
gr. A^ daily (Voinovitch), or sulphate of morphine, gr. 
three times a day (Leubuscher, Schaeifer), may be used tem- 
porarily. 

In achylia gastrica the gastric juice is not formed. A posi- 
tive diagnosis is based upon repeated examination of the 
stomach-contents and the exclusion of cancer. The small 
intestine perfectly replaces the digestive work of the stomach, 
and the organism is not only enabled to maintain its equi- 
librium, but also to gain in weight (Einhorn). 

In the way of treatment, the stomach may be stimulated by 
lavage, direct faradization, and the use of condurango or nux 
vomica. The food should be thoroughly masticated, that it 
may be more easily digested in the intestine. 

Ischochymia is marked by a retention of food (chyme) in 
the stomach, even in the fasting condition. The condition 
may be due to a lessening of the motor function of the stomach, 
or to stenosis of the pylorus, organic or spasmodic. 

In diagnosis, most important is the difiFerentiation between 
benign and malignant stenosis of the pylorus, which may 
be made by the duration and course of the disease, the 
presence or absence of tumor, and the examination of the 
contents of the stomach as to odor, acidity, and the pres- 
ence or absence of free hydrochloric acid, lactic acid, and 
rennet. 

The treatment depends largely upon the cause. Lavage and 



GASTRIC NEUROSES. 



203 



spraying the stomach with nitrate of silver, 1 : 1000 to 3 : 1000, 
are recommended. Malnutrition may call for rectal alimen- 
tation. 

GASTRIC NEUROSES: SENSORY. 

Hyperorexia : Bulimia (ox-hunger), cynorexia (dog-hunger), 
is marked by a great increase of hunger. 

The diagnosis of hyperorexia as a primary affection should 
be based upon the abnormal hunger and the exclusion of other 
affections to which such a condition may be secondary, such 
as ulcer of the stomach, hyperchlorhydria, carcinoma of the 
stomach, intestinal troubles, tapeworm, diabetes. Graves' dis- 
ease, hysteria, neurasthenia, and tumors of the brain. 

In treatment, food should be administered in s:iiall quan- 
tities everv two hours. The bromides mav be o^iven in laro^e 
doses twice a day ; or cocaine (Rosenthal) 3-5 cgm. twice a 
day ; or opium or codeine 3-4 cgm. three times a day ; or 
arsenic, Fowler's solution, two or three drops two or three 
times a day. Severe and persistent cases call for a change of 
climate, to the mountaius or seashore. 

Parorexia perversion of appetite, may occur as malacia, a 
craving for highly seasoned food and spices, mustard, salad, 
vinegar, green fruits, etc. ; pica, a desire to eat substances not 
commonly used as food, such as coal, ashes, chalk, earth, sand, 
insects, etc. ; and aUotriophagia, in which tlie appetite calls 
for disgusting and harmful substances, f^ecal matter, needles, 
pins, etc. Malacia may occur in many disturbances of the 
stomach and in neurasthenia ; pica and aUotriophagia are 
found in bad cases of hysteria, more frequently in idiots and 
the insane. 

Polyphagia is a condition in which abnormal quantities of 
food are required to secure a feeling of satiety. The condition 
may occur as a primary affection in neurotic individuals. As 
a secondary affection, polyphagia occurs especially in carcinoma 
of the pancreas and spleen, fistulous openings of the gall- 
bladder, diabetes, in some cases of brain-tumors, and in the 
conditions in which we find hyperorexia as a secondary affec- 
tion. 



204 DISEASES OF THE ORGANS OF DIGESTION. 



Akoria, a condition in which a feeling of satiety may not 
be experienced, is found especially in neurasthenia and hys- 
teria, and in the conditions in which hyperorexia and poly- 
phagia occur secondai'ily. The condition often occurs in 
association with polyphagia. 

Anorexia, an absence of hunger and appetite, occurs in 
many organic and so-called functional disorders of the stomach. 
A diagnosis of nervous anorexia involves the exclusion of or- 
ganic affections, cancer, tuberculosis, etc., in which anorexia 
may occur as a secondary condition. 

A valuable point in the diagnosis of nervous anorexia is the 
fact that the loss of appetite causes no alarm on the patient's 
part. 

In the treatment of mild cases it is sufficient to offer the 
patient nourishment regularly and in ample variety, without 
previous reference to the diet, and then to impress upon him 
the importance of eating. The patient may receive, fifteen or 
twenty minutes before meals, tincture of nux vomica, gtt. x 
three times a day, or fluid extract of condurango, gtt. xx three 
times a day, or fluid extract of Peruvian bark a teaspoonful 
three times a day, or orexicum basicum gr. iij-ivss three times 
a day. More severe cases call for isolation and the ''rest cure,'' 
with massage and electricity. Persistent refusal of food may 
demand forced feeding, gavage, through the stomach-tube. 
Iron and arsenic. Fowler's solution or Roncegno w^ater, may 
be advantageously administered. Exercise in the fresh air is 
a valuable tonic. 

Gastric hyperaesthesia, apart from gastric catarrh, erosions, 
ulcer, and carcinoma, occurs especially after chlorosis, excess 
in venery, and persistent indulgence in improper food. 

Treatment as far as possible should address the underlying 
condition. Chlorotic cases are benefited by iron. In other 
cases, as a rule, most may be accomplished by the use of the 
bromides. 

Gastralgia, pain in the stomach, more or less severe, periodic 
in character, may occur in connection wdth ulcer, cancer, 
hyperchlorhydria, adhesions of the peritoneum, or after the 



GASTRIC NEUBOSES. 



205 



iDgestion of certain foods or spices to which the patient is not 
accustomed. 

Some cases are distinctly of central origin^ found especially 
in connection with spinal disorders, tabes dorsalis, subacute 
myelitis, pressure-myelitis ; much less frequently diseases of 
the brain, and sclerotic degeneration of the nucleus or trunk of 
the vagus. 

Grastralgia often occurs in hysteria and neurasthenia, and in 
the infections, especially malaria. 

Among the intoxications that may cause gastralgia are 
chronic lead-poisoning, the excessive use of mercury, and the 
use of tobacco. Cases may be caused by gout, anaemia, and 
chlorosis. 

Among the reflex causes are diseases of the genito-urinary 
organs, displacements of various abdominal organs, and hydro- 
nephrosis. 

The diagnosis of nervous gastralgia demands the exclusion 
of chronic gastric catarrh, carcinoma of the stomach, ulcer of 
the stomach, stenosis of the pylorus, hyperchlorhydria, gastro- 
siiccorrhcea continua periodica and chronica, achylia gastrica, 
and conditions in which the pain is outside of the stomach, 
such as muscular pain due to rheumatism or over-exertion, 
intercostal neuralgia, gall-stones, kidney--t' tnes. and enteralgia. 

Treatment, when possible, should address the underlying 
condition. The attacks should be relieved by hot applications 
and drinks. Intense pain may demand morphine hypoder- 
matically, or codeine or opium with belladonna or atropine 
in suppositories. 

GASTEIC NEUROSES : MOTOR. 

Cardio spasmus, a spasm of the cardia, may be either acute 
or chronic. The condition should be differentiated from or- 
ganic stricture, best by the use of the cesophageal sound or 
stomach-tube. Often a large sound or tube will enter more 
readily than a small one. 

Treatment. Acute cases call for the bromides and the reg- 
ular use of the sound. In chronic cases the food must be at 
first fluid or semifluid, and the stomach-tube should be tised 



206 DISEASES OF THE ORGANS OF DIGESTION. 



every evening before retiring. Later the usual diet may be 
gradually resumed. 

Eructation is a belching of gas. Pyrosis, "heartburn/' is 
an ejection of some of the contents of the stomach into the 
oesophagus. Regm-gitation implies an ejection of the food 
from the stomach into the mouth. Rumination is commonly 
known as " chewing the cud.'' 

Nervous vomiting can be said to exist only after a careful 
attempt to exclude abnormal conditions of the stomach or of 
the food. Among the causes of nervous vomiting are spinal 
or cerebral irritation, neurasthenia, hysteria, and diseases of 
distant organs which may act reflexly. 

Pneumatosis, distention of the stomach with gas, is frequently 
associated with neurasthenia and hysteria. Organic affections 
must be excluded. 

Hyponakinesis ventriculi : Reduction of the mechanical 
power of the stomach. 

Hyperanakinesis ventriculi : Exaggeration of the mechanical 
function of the stomach. When the peristalsis of the stomach 
becomes visible upon inspection, the condition is known as 
peristaltic restlessness when the waves proceed from left to 
right ; and antiperistaltic restlessness when the waves move 
from right to left. 

Pyloric incontinence may be caused by neoplasms or atony 
of the pylorus. The condition is recognized especially by 
regurgitation of the intestinal contents, bile, into the stomach 
in considerable quantities, which may be revealed by the 
stomach-tube. The rapid passage of food from the stomach 
into the intestine, so that the stomach is found empty sooner 
than normal, may be due to incontinence of the pylorus, but 
more frequently is caused by hyperproGhoresis, increased motor 
function. 

Pylorospasmus, spasm of the pylorus, may occur inde- 
pendently of demonstrable organic disease. 



GASTRIC NEUROSES. 



207 



Atony of the stomach refers especially to a weakened or 
retarded muscular action. The condition is found most fre- 
quently in chronic gastric catarrh, hyperchlorhydria, neuras- 
thenia, tuberculosis, and heart-disease. 

Sometimes atony occurs as a primary neurosis, the symptoms 
of which are fulness after meals, eructations of gas, diminished 
appetite, and frequently headache and constipation. 

The treatment calls for intragastric faradization (Einhorn), 
strychnine, tincture of mix vomica, fluid extract of condu- 
rango, and iron. The diet should be light and contain little 
fluid. Mental work and anxiety must be avoided. Outdoor 
exercise is of value. Constipation should be remedied. 

GASTRIC NEUROSES : SECRETORY. 

It is well known that the gastric secretion may be increased 
by the sight of food, and decreased by fear and anxiety. Dis- 
turbances of secretion, hyperchlorhydria, hypochlorhydria, or 
achylia gastrica, may be of nervous origin. 

Nervous dyspepsia (Leube), neurasthenia gastrica (Ewald), 
is a condition in which there are dyspeptic symptoms in the 
absence of any demonstrable organic lesion, when on examina- 
tion the secretion of gastric juice is found to be normal and 
the stomach is empty seven hours after a test-dinner. 

Etiology : Nervous dyspepsia frequently forms a part of 
neurasthenia and hysteria, and is found often in chlorosis, dis- 
eases of the lungs (tuberculosis), the infections (malaria), dis- 
eases of the genito-urinary organs, and in cases of sexual 
excess and abuse of tobacco and alcohol. 

Symptomatology : The appetite is capricious. The tongue 
is usually clean, sometimes coated. During gastric digestion 
there are slight pain in the stomach, belching, sometimes 
drowsiness and headache. When the stomach is empty there 
may be a feeling of weakness and dizziness. Usually there 
is depression of spirits. Later the symptoms become aggra- 
vated, and there is loss of weight. 

The diagnosis depends upon the presence of dyspeptic symp- 
toms and the absence of organic disease, A useful point in 



208 



DISEASES OF THE ORGANS OF DIGESTION. 



diagnosis is the fact that the symptoms are not affected by the 
character of food ingested, but may be relieved by change 
of climate and pleasant mental emotions. 

The differential diagnosis concerns especially chronic gastric 
catarrh, ulcer, and carcinoma. 

Treatment : Existing ailments which may have an etiological 
relation to nervous dyspejysia should receive proper attention. 
Change of climate, especially a change from indoor to outdoor 
life, relief from mental anxiety and business and family cares, 
the ingestion of plenty of wholesome food, and the "rest 
cure," give the best results. The nervous system may be 
strengthened by mild hydrotherapeutics, massage, electricity, 
and moderate gymnastics. Of medicines, the bromides are 
largely used. Iron, arsenic, nux vomica, and basic orexin 
are often of value. Sleeplessness may be overcome with 
chloral, sulfonal, or trional. The bowels should be regulated. 

Condition of the stomach in diseases of other organs : Dis- 
turbance on the part of the stomach is especially marked in 
pulmonary tuberculosis, sepsis, chlorosis, and anaemia ; diseases 
of the heart, liver, or kidneys; diabetes, arthritis deformans, 
gout, and malaria. 

DISEASES OF THE INTESTINES. 

INTESTINAL CATARRH (Enteritis (Inflammation of the Small 
Intestine); Colitis (Inflammation of the Large Intestine); 
Entero- colitis (Inflammation involving both the Small and 
Large Intestine)). 

Localized inflammations have received special names : duo- 
denitis, typhlitis, proctitis, etc. 

Catarrh of the intestine may be either acute or chronic. 

Etiology : Acide catarrh of the intestine may be caused by 
errors in diet, especially the ingestion of spoiled food, tainted 
meat, fruit, milk, bad water, or by irritant substances, organic 
(drastic cathartics, colocynth, croton oil, carbolic acid) or in- 
organic (metal poisons, arsenic, corrosive sublimate, tartar 
emetic, and the caustic alkalies). Bacteria play a prominent 
role in the etiology of this disease. Many cases are attributed 



INTESTINAL CATARRH. 



209 



to "catching cold." Among the mechanical causes are entero- 
liths, gall-stones, and intestinal parasites. An acute duo- 
denitis may be caused by burns of the skin, probably 
through the action of toxins. Catarrh of the intestine may 
be caused secondarily by diseases of the mouth or stomach, 
acute infectious diseases, chronic cachexias, heart-disease, kid- 
ney-disease, tuberculosis pulmonum or intestinalis, diabetes, 
strangulation, volvulus, invagination, peritonitis, thrombosis, 
and embolism. 

Streptococcus enteritis is often complicated by septic invasion 
of other organs, especially the liver, kidneys, spleen, and heart. 

Chronic catarrh of the intestine may be primary or follow 
an acute catarrh through continuance or repetition of the 
cause. Most cases depend upon ulcerative processes : typhoid 
fever, tuberculosis, dysentery, carcinoma, and syphilis. 

Symptomatology : Acute catarrh of the intestine usually 
begins suddenly with pain (colic) and diarrhoea. The diar- 
rhxa is caused by increased peristalsis and decreased absorp- 
tion. Mucus and fluid are excreted by the intestine. There 
are from two or three to twenty or more stools in the twenty- 
four hours. There may be tenesmus when the catarrh ex- 
tends to the large intestine. The stools are at first fsecal ; 
then thin, later watery. Sometimes there is no diarrhoea, 
through absorption of fluid in the large intestine. Bile-pig- 
ment is frequently present in the stools, especially when the 
catarrh involves the upper part of the small intestine. The 
stools of infants and small children are, or become on standing, 
green from oxidation of the bile-pigment. Sometimes there 
is icterus. There are borborygmus and meteorism. Upward 
pressure of the diaphragm may cause dyspnoea, palpitation, 
and precordial distress. There are early malaise and prostra- 
tion. Fever is usually absent, but may reach 102° F. Con- 
vulsions or delirium may supervene in Aveak individuals, 
especially children and the aged. The loss of considerable 
fluid through diarrhoea causes diminution of the urine, some- 
times anuria, and increased thirst. There are anorexia and 
nausea, except when the catarrh is limited to the large intes- 
tine. Burning, itching, pain, and tenesmus may be distressing 
in catarrh of the rectum. 



14— p. M, 



210 DISEASES OF THE ORGANS OF DIGESTION. 



In chronie catarrh of the intestine, diarrhoea may alternate 
with constipation. Constipation is more frequent than con- 
tinuous diarrhoea. Tenesmus often causes hemorrhoids. Miicjis 
is always present, and sometimes may be passed in large quan- 
tities. Sometimes the stools contain blood and A proc- 
titis may extend to constitute a periproctitis, Avith the forma- 
tion of abscess, which by bursting may cause an external 
rectal, recto-vesical, or recto-vaginal fistula. The subjective 
symptoms of chronic catarrh are similar to those of acute 
catarrh. The general symptoms may be more pronounced. 
The mucous membrane is sometimes destroyed, or undergoes 
atrophy, to cause persistent chronic diarrhoea, anaemia, and 
debility. When this is combined with atrophy of the stomach, 
there may be the picture of pernicious anaemia (Osier, Noth- 
nagel, Ewald). 

Diagnosis: Catarrh of the duodenum is often caused by ex- 
tensive burns of the skin. The condition may be recognized 
by the presence of icterus, tenderness in the right hypochon- 
drium following catarrh of the stomach, and the passage of 
large quantities of mucus. 

Catarrh of the small intestine shows indican in the urine, 
which may be recognized by the Bnrgundy-red reaction of 
Rosenbach. Boil the urine in a test-tube, adding nitric acid 
drop by drop. A Burgundy or peony-red color, which is 
retained on further boiling and which may be extracted with 
ether, is indicative of a disturbance of the metabolic processes 
in the small intestine. 

Catarrh of the large intestine, especially of the rectum, is 
indicated by anal itching and burning sensations, tenesmus, 
pain in the left iliac fossa, the passage of mucus, sometimes 
of blood, and considerable pain on digital examination, espe- 
cially when the lower part of the large intestine is affected. 

Chronic catarrh of the intestine may show constipation. 
The passage of mucus is especially prominent. 

A careful differentiation should be made between primary 
and secondary catarrh of the intestine. 

Most important is the discovery of the cause of the catarrh. 

Prognosis is more serious in infancy and old age, but de- 
pends largely upon the cause. In cases of long duration the 



ISTESTIXAL CATARRH. 



211 



outlook becomes more unfavorable through the clanger of 
atrophy or ulcer. In secondary catarrh of the intestine the 
prognosis depends chiefly upon the gravity uf the primarv 
disease. 

Treatment: MUd cases of intestinal catarrli may require no 
treatment further than the removal of the cause, with absti- 
nence from food for a short time and later a light diet, begin- 
ning possibly with diluted milk and gradually returning to 
the normal diet. Offending material must be removed fr<>m 
the intestine, best by calomel or castor oil internally and l)y 
cleansing enemata. Some prefer the biniodide of mercury. 
Abdominal pain and tenesmus may be relieved by warm or 
hot applications, or opium in the form of kiudanum inter- 
nally or the extract in suppositories. An excellent formula, 
given by Whittaker, is : 

II Tinctur^e opii, gtt. xl-lx ; 

Acidi hydrochlorici diluti, gtt. xl ; 

AqtiLC camphor^e, ad siv. 

M. S. A teaspoonful to a tablespoouftil every two 
to four hours. 

Antiseptic and astringent remedies may be used internally 
and by enemata. Ewaid recommends : 

R. Resorcin, (o.Oj gr. Ixxv ; 

Bismuthi salicylat., 
Tannigen, aa (15.0) 5ss; 

Sacchari albi, 

Sodii carbonatis, da (7.5) 5ij- 
M. ft. pulv. 

S. Small even teaspoonful to be taken every two 
hours. 

The intestine may be irrigafprl with a solution of nitrate 
of silver, with boric acid, tannic acid, or alum. Ewald 
prefers ; 



212 DISEASES OF THE ORGANS OF DIGESTION. 



^. Chloral, (3.0-5.0) gr. Ixv-lxxv ; 

Acidi tannici, (^-5) gr. xxiv ; 

Lime water, ad (500.0) Oj. 
M. S. One-quarter to one-third of this quantity 
is to be mixed with 12 ounces of warm water 
or thin starch-water, and of this 5 or 6 
ounces or more may be injected into the 
bowel and should be retained as long as 
possible. 

Carlsbad salt is one of the best laxatives. 

Chronic catarrh of the intestine — treatment: Diet is most 
important. The drinking-water should be pure (boik^d). In 
addition the treatment recommended for acute catarrh of the 
intestine may be indicated. Constipation frequently needs 
treatment. Sometimes a stay at one of the mineral springs 
may be necessary. 

Catarrh of the intestine in infancy and early childhood: 
Food should be withdrawn for a time. During the interval 
the patient may be given boiled water, to which may be 
added a pellet of salt. Cases of chronic catarrh sometimes 
call for a change of diet. Lavage is often of value. Irritant 
material must be removed from the intestine, usually best by 
the administration of calomel or castor oil. Diarrhoea often 
is relieved by the administration of bismuth subnitrate, or 
tannalbin. More persistent cases may be relieved by a com- 
bination of ipecac and opium. Sometimes persistent vomiting 
is relieved by creosote. 

ULCER OF THE INTESTINE. 

Typhoid ulcer (see Typhoid Fever). 
Tuberculous ulcer (see Tuberculosis). 

Catarrhal and follicular ulceration have been treated of under 
Catarrh of the Intestine. 

Round Duodenal Ulcer (Ulcus Duodeni Pepticum). 

Ulcer of the duodenum is found in men more frequently 
than in women. It is believed that the gastric juice enters 



INTESTINAL HEMORRHAGE. 



213 



the duodenum and causes corrosion when there has been a 
local circumscribed disturbance of circulation. Ulcer of the 
duodenum frequently appears after severe burns of the skin. 
Some attribute such cases to toxic material eliminated by the 
bile (Hunter) ; others believe it to be due to the liberation of 
the fibrin-ferment causing thrombosis of the duodenal veins. 

Duodenal ulcer — symptomatology : Sometimes there are no 
symptoms. Some three hours after meals there may be pain 
in the region of the duodenum radiating toward the epi- 
gastrium and sacrum, sometimes very closely simulating gall- 
stones. The pain is not increased by food. Usually there 
is diarrhoea. More characteristic is hemorrhage^ appearing as 
melcena, sometimes with hsematemesis, very rarely as hsemat- 
emesis alone. There are tenderness and anorexia. Sometimes 
induration may be detected. 

Diagnosis : Duodenal ulcer should be differentiated from 
ulcer of the stomach, gall-stone colic, carcinoma of the duode- 
num, and the gastric crises of locomotor ataxia. 

Ulcer of the stomach may be eliminated by the location of 
the circumscribed point of tenderness, the time of occurrence 
of the pain after taking food, the examination of the contents 
of the stomach, showing an absence of hyperchlorhydria, and 
an examination of the urine for peptone. The time of occur- 
rence of pain and hemorrhage would speak against gall-stone 
colic. Carcinoma runs a shorter course, and frequently 
presents the symptoms of stenosis, and is accompanied by 
cachexia and more marked degradation of health, and often a 
tumor may be detected. The gastric crises of locomotor 
ataxia may be ruled out by the absence of symptoms on the 
part of the central nervous system, indicative of locomotor 
ataxia. The prognosis is not favorable. 

Treatment: Special attention should be paid to the diet and 
all indiscretions avoided. Sometimes it is necessary to resort 
to rectal alimentation. Otherwise the treatment is symp- 
tomatic. 

INTESTINAL HEMORRHAGE ( Enter orrhagia). 
Etiology : Ulcercdion of the intestines is the most common 
local cause of intestinal hemorrhage. Other conditions to 



214 DISEASES OF THE ORGANS OF DIGESTION. 



which hemorrhage may be due, are : inflammation of the in- 
testinal mucosa, inflammation and ulceration following burns 
of the skin ; intussusception : obstruction of the portal circu- 
lation ; disease of the heart, lungs, bloodvessels, and liver ; 
obstruction of the mesenteric arteries, and rupture of an 
aneurism into the intestine. Hardened faeces or foreign bodies 
passing through the intestine may cause slight hemorrhage. 
Hemorrhage may be caused by foreign bodies passed into the 
rectum by accident or design, as frequently occurs among the 
insane. The excessive use of purgatives or the ingestion of 
caustic or corrosive poisons may produce hemorrhage. 

The infections may cause hemorrhage either through an 
action upon the mucosa of the intestine, as in the ulceration 
of typhoid fever, syphilis, and dysentery ; or through an action 
upon the blood and vascular system, as in typhoid fever (before 
ulceration), yellow fever, plague, septicaemia, malaria, scurvy, 
purpura, haemophilia, uraemia, and cholaemia. Hemorrhage 
from the intestine is sometimes an expression of vicarious 
menstruation. Hemorrhoids, ulcers, polypi, carcinomata, and 
tuberculosis intestinalis may be marked by hemorrhage. 

Intestinal hemorrhage — symptomatology : There may be 
only collapse, without the passage of blood, sometimes with- 
out preceptible distention of the abdomen. Blood from the 
upper part of the intestines is sometimes regurgitated into the 
stomach and discharged by hcematemesis. As a rule blood ap- 
pears in the stools. The amount may be so small as to be 
detected only Avith the microscope, and sometimes blood may 
be discovered in this way before the appearance of gross hem- 
orrhage (thirty-six hours before, Nothnagel). Hemorrhage 
high up in the intestinal canal may appear as black (tarry) 
stools. In hemorrhage from the colon, the passages may be 
covered or streaked with blood and mucus. When retained 
for a long time the blood may become inspissated. 

Diagnosis : The stools should be carefully examined to 
detect the presence of blood. In doubtful cases an exami- 
nation may be made with the microscope or spectroscope. 
Next the source of the hemorrhage should be determined, 
whether from the mouth, nose, pharynx, larynx, lungs, oesoph- 
agus, stomach, or intestine. Swallowing of blood is found 



TYPHLTTIS. 



215 



especially among malingerers, the new-born, and infants 
nursing from bleeding nipples. Examination of tlie anus 
and rectum may reveal hemorrhoids, ulcers, or polypi. Sud- 
den collapse should awaken the suspicion of latent hemor- 
rhage. 

The prognosis depends largely upon the cause. A copious 
and persistent hemorrhage is always dangerous. 

Intestinal hemorrhage— treatment : The foot of the bed 
should be raised. The diet may consist of milk, ice, and 
cold drinks. Cold applications — the ice-bag — should be 
placed over the abdomen. Opium may be given to restrain 
peristalsis. Liquor ferri persulphatis or pernitratis, tannic 
acid, or gallic acid, may be given internally. Ergotol, the 
aqueous extract of ergot, ergotin, or sclerotinic acid, may be 
injected subcutaneously. Astringent solutions, tannic acid, 
gr. j : of ice-water, or nitrate of silver, gr. \ : 5j, may be 
injected into the bowel, when the hemorrhage comes from the 
rectum or lower part of the intestine. Any underlying con- 
dition should be properly treated. Thus malaria may call for 
quinin. 

Collapse demands the use of the analeptics. 
Lyman recommends — 

^. Moschi, 

Pulv. camphorse, 

Pulv. capsici, ad gr. j. 

M. Fiat pilula JSTo. j. 
Sig. Give one such pill every two to four hours. 

Bad cases call for the use of camphor hypodermatically, 
best dissolved in olive oil or ether. Salt water infusion may 
rescue even desperate cases. 

TYPHLITIS (Perityphlitis; Paratyphlitis), 

Typhlitis (csecitis) is a colitis limited to the wall of the 
csecum. The chief causes are improper food and trauma, gall- 
stones, enteroliths, foreign bodies, and the infections, typhoid 
fever, tuberculosis intestinalis, syphilis, dysentery, intestinal 



216 



DISEASES OF THE ORGANS OF DIGESTION. 



diphtheria, carcinoma, and actinomycosis. When due to irri- 
tation from masses of fseces^ the condition is known as typiditis 
stercoralis. 

Typhlitis — symptoms : The onset of symptoms is gradual. 
There is pain in the ileo-cseeal region^ dull in character, some- 
times paroxysmal, increased by pressure or movement, some- 
times radiating to tlie umbilicus, right hypochondrium, or the 
epigastrium. The usual symptoms of dyspepsia, eructations, 
nausea, rarely vomiting of food or bile, are more or less 
marked. There are constipation, and usually some distention 
of the abdomen. A soft sausage-shaped tumor may be found 
in the right iliac fossa. The temperature usually is not very 
high, but frequently reaches 102° F. The urine, diminished 
in quantity and high colored, may contain small quantities of 
albumin and indican. 

The prognosis of typhlitis is good. 

In the treatment of simple typhlitis the bowels should be 
moved thoroughly with an enema of water or oil, combined 
if necessary with the internal use of castor oil. In simple 
typhlitis stercoralis the enema may be repeated, if necessary, 
with the administration of castor oil, calomel, or Carlsbad 
salt. 

Perityphlitis, an inflammation of the peritoneal covering of 
the csecum, and paratyphlitis, an inflammation of the perito- 
neum and connective tissue behind the caecum (retrocsecal), as 
a rule, accompany appendicitis rather than typhlitis, although 
their relationship with typhlitis in some cases may not be 
denied. 

a i Perityphlitis belongs to the surgeon,' has been until 
lately an assertion defended with emphasis by many sur- 
geons, but which has never received the assent of the general 
practitioner, and never will. According to the experience of 
general practice, and the statistical results of Sahli, Renvers, 
Guttmann, Leyden, Fiirbringer, Hollander, Rotter, and the 
majority of French physicians, from 90 to 91 per cent, of all 
cases of perityphlitis, taken in the widest sense, recover with- 
out any operation. It would, therefore, smack of insanity to 
subject every case of perityphlitis to the uncertainties of an 
operation" (Ewald). 



APPENDICITIS. 



217 



APPENDICITIS. 

Appendicitis : Inflammation of the vermiform appendix is 
usually nor confined to the appendix, but extends to consti- 
tute a perityphlitis, or more correctly a peri-appendicitis. 

Etiology : The infectious agent is usually the bacillus coli 
cormmini.s. sometimes associated with the streptococcus pyo- 
genes or the staphylococcus pyogenes aureus or citreus or 
other bacteria, especially diplococci, usually as a secondary 
infection. Causes predisposing to such infection are : irrita- 
tion due to arrest of the contents of the intestine, the con- 
tinued retention of feecal matter in the caecum, bending or 
twisting of the appendix, and muscular relaxation of the wall 
of the appendix; excesses in eating, violent exercise soon 
after eating, and the ingestion of substances of an irritating 
(mechanical or chemical) character. 

Bacteria grow readily in the mucus, sometimes mixed with 
faecal matter, contained in the appendix. The appendix may 
be occluded or irritated by inspissated masses of faecal mat- 
ter, gall-stones, enteroliths, rarely foreign bodies, such as the 
eggs of ascarides, fish-bones or other small bones, bristles, 
hairs, and seeds. Sudden perforation may occur from necrosis 
of the wall of the appendix. 

Appendicitis — symptomatology : Most cases occur between 
fifteen and thirty years of age, rarely before the third year, 
although the disease has been reported as early as the seventh 
week of life. Males are probably most frequently affected. 
There are often repeated relapses or recurrences. 

A simple caiarrlial appendicitis may show no symptoms. 
Pain, dull, boring or stabbing, may appear in the ileo-ccecal 
region, sometimes at the umbilicus or epigastrium, as repeated 
attacks of colic, which may occur in mild cases only when 
peristalsis is increased. A careful physical examination may 
reveal the swollen appendix. 

More severe cases of appendicitis may show didness, more 
or less marked, over the region of the appendix, and palpa- 
tion may detect resistance resembling a tumor near the border 
of the right ilium. There are pcnn, abdominal distention, 
dyspeptic symptom.-<, sometimes vomiting of food, bile, medi- 



218 DISEASES OF THE ORGANS OF DIGESTION. 



cine, possibly stercoraceous vomiting, with constipation and 
some fever. The loine is scanty, high colored, gives the 
Burgundy-red reaction, and may contain indican. 

In a third class of cases of appendicitis there is bacterial 
invasion of the peritoneum^ sometimes but not always through 
perforation (necrosis, ulceration). There is violent abdominal 
pain after intestinal disturbances, trauma, the swallowing of 
some foreign body (bone, seed), sometimes without apparent 
cause. The pain later becomes localized in the region of the 
appendix. The temperature may rise above 102° F. Hic- 
cough is a prominent symptom in many cases. Constipation 
is the rule ; occasionally there is diarrhoea. Movement causes 
pain. There may be the symptoms of collapse. Phys- 
ical examination may reveal a large perityphlitic accumu- 
lation. 

In chronic cases the pus may burrow, to find exit in the 
most various ways. 

Diagnosis : In the presence of typical symptoms the diag- 
nosis is easy. Of most importance, as a rule, are the previous 
history and the presence of a tumor or dulness in the region 
of the appendix. Tenderness may be elicited at JfcBurney^s 
point. 

The differential diagnosis calls especially for the separation 
of renal colic, hepatic colic, and in chronic cases cancer and 
tuberculous peritonitis. Often appendicitis is tubercular. 
The inflammation may not be confined to the usual region of 
the appendix, so that it may be necessary to rule out peri- 
nephritic inflammation, hsematocele, salpingitis, pyosalpinx, 
cholelithiasis, or disease of the liver; or to recognize an 
appendicitis occurring in a hernial sac in the scrotum or else- 
where. Confusing symptoms may sometimes be caused by 
constipation from opium, invagination, or strangulation. Some- 
times a positive diagnosis can be made only upon exploratory 
incision. 

Appendicitis — prognosis : When appeal is to be made to 
surgery, the earlier such treatment is instituted the better will 
be the prognosis. Suppurative peritonitis gives a bad outlook. 
The occurrence of complications increases the gravity of the 
case. The prognosis is unfavorable when the peritonitis 



INTESTINAL OBSTRUCTION 



219 



becomes general, or in tne presence of a suppurative pleurisy, 
pylephlebitis, or abscess of the liver. 

Prophylaxis : The bowels should be regulated. Especially 
must constipation be remedied. Food is to be avoided that 
would cause constipation or leave a large residue in the bowel. 
The meals should be eaten slowly and thoroughly masticated. 
The patient should rest for a while after meals. Indigestible 
substances, such as the seed of fruit, should not be swallowed. 
The danger of trauma, as far as possible, must be avoided. 

Appendicitis — treatment : During the attack the patient 
must observe absolute rest in bed. The diet should be light ; 
best nothing but boiled water and cracked ice for the first 
twenty-four to thirty-six hours. Later milk may be given, 
cold or lukewarm ; then small quantities of oatmeal, farina 
soup, or bouillon made from white meat. The return to the 
normal diet should be very gradual. 

Pain calls for the use of opium, with applications of cold 
(cold compresses, ice-bag), or of heat (hot compresses, poul- 
tices), and infusions of chamomile, valerian, etc. 

Constipation, even wdien obstinate, may be allowed to run 
several days during the acute stage of an attack without 
treatment. The bowels may then be gently moved by small 
enemata carefully given. Should these fail, high injections 
may be given of water containing castor oil, made into an 
emulsion with the yolk of an egg. When necessary, purga- 
tives may be administered internally, best castor oil ; later 
calomel or Carlsbad salt may be given. 

Operation may be demanded by perforation, suppuration, 
recurrence of attacks wnth increasing severity, when the opera- 
tion should be made between attacks, and in cases of chronic 
appendicitis with indefinite and obscure symptoms. It is not 
infrequent to find an apparently healthy appendix at opera- 
tions in cases in which the clinical symptoms have been those 
of appendicitis (Ramm). 

INTESTINAL OBSTRUCTION (Ileus; Intestinal Occlusion). 

Etiology : Obstruction of the intestine may be caused by 
abnormal conditions of the intestine, of the intestinal con- 



220 DISEASES OF THE ORGANS OF DIGESTION. 



tents, or by compression from tumors, misplaced organs, etc. 
Chronic or habitual constipation may be present even when 
there is the history of daily stools. The condition may be 
due to atony of the bowel or a weakening of the muscle- 
fibres of the intestine through inefficient efforts to overcome 
some chronic obstruction of the bo\vel ; irregular habits of 
defecation ; leaving too much or too little residue to pass 
through the intestine, or a diet without variety, such as an 
exclusive meat-diet, or food containing too little water, or 
the loss of water through the skin (profuse perspiration), 
lungs, or kidneys; abuse of purgatives, fatiguing the mus- 
cular fibres ; change from an active outdoor to an indoor 
sedentary life • mechanical pressure (pregnancy) ; preoccupa- 
tion of the mind by business or domestic cares, melancholia, 
insanity. 

Intussusception, or intestinal invagination, may occur physio- 
logically during the so-called death-agony, and possibly at 
other times. Intussusception occurs pathologically most fre- 
quently in children, half the cases before the tenth year ; in 
males -more frequently than in females. The condition occurs, 
in the order of frequency, as ileo-c8ecal invagination, enteric 
invagination, and colic invagination. Invagination of the 
duodenum is rare. 

Internal strangulation usually affects the small intestine, the 
lower part of the ileum, and is most frequent under forty. 

Stricture may result from cicatrization following ulceration 
(dysentery, less frequently typhoid fever, tuberculosis). More 
often stricture is due to syphilis or carcinoma and may be 
recognized by rectal examination. 

Obturation of the intestine may occur from the lodgment 
of gall-stones, more rarely from enteroliths, as a rule having 
as a nucleus some foreign body. Calculi may be caused by 
the continued medicinal use of mineral substances, such as 
calcium carbonate, calcined magnesia, or magnesium carbonate. 

Volvulus, a turning of the intestine around its mesentery or 
upon its own axis, occurs most frequently after forty, usually 
at the sigmoid flexure. A^olvulus is caused as a rule by 
chronic constipation, sometimes by chronic peritonitis, and 
may be, rarely, congenital. Twisting of the intestine has 



INTESTINAL OBSTRUCTION. 



221 



been ascribed to violent irregular movements of the intestine, 
jumping, trauma, and the use of high injections. In such cases 
peritonitis may occur early, but perforation is rare. With- 
out operation death usually occurs in two to six days. One 
case is reported to have lived twenty days (Treves). Twist- 
ing of the intestine upon its own axis occurs only in the 
caecum and ascending colon. Volvulus of the ileum or 
jejunum is rare. 

Collapse may supervene suddenly. There is violent pain, 
often intermittent, with vomiting, slight in quantity but faecal 
in character. The convolution above the volvulus is dis- 
tended and fixed. It is impossible to introduce water or air 
through the rectum past the obstruction. There is early 
tenesmus. The urine does not contain indican. There may 
be only half a turn of the bowel, constituting an incomplete 
volvulus. 

In addition to the causes already enumerated, obstruction of 
the intestine may be caused by compression from a tumor or 
from some other organ : displaced uterus, dislocated spleen, 
floating kidney. 

Cases in which no other cause can be found are supposed 
to be due to a circumscribed intestinal paralysis, so-called 
cases of paralytic ileus. The condition may be only an 
arrested peristalsis or an actual paralysis, and may be due to 
trauma, appearing sometimes after the reduction of a hernia ; 
inflammation, peritonitis, or to other causes which may not be 
easily discovered. 

Symptomatology : The onset of the symptoms of ileus may 
be gradual or sudden. Where the obstruction is complete, 
the constipation may amount to obstipation. Usually there is 
jmin, which may be present in every grade of severity, and 
either intermittent or constant. There are tormina and tenes- 
mus. The pain comes on earlier and is more marked when 
the small intestine is involved. The pain is not always 
referred to the point of obstruction. There are singultus ; 
eructations ; later vomiting, which is at first, or soon becomes, 
stercoraceous. The abdomen is more or less distended and 
tender. Percussion reveals meteorism in cases of acute ob- 



'I'JL'l hll^I'lASI'lH O/' 77//'; OliCANS O/-' hldl'lS'l'ION. 



Hl,r'ii(;(,i<»ii, wlii'li I (lit III \\\(: ()<:(:\ii~An\\ fVorri C-Oiislip;! I ion. 

Til*' tiriiiM iH <liiii))ii Im 'I III (ju;uilil y, oi liij/fi spocifif; ^nivil-y, 
<',on(;)ifi;- mul' . In<ln;nnu,rut, ;i |>|)(;;i t'.-. ('iifly in olj-lfnr,- 
I ion <»(' I lie ni;ill inl'-:-:l in*;, :i,nd l;it< of nol ;ill in ol>;-l,r n'-l iofj 
iii iJic l.-itv"' jnic I Ml'', :in<l i;-; HffiaJI in ;inioinil wli' ii I li'- olj I ruo- 
rioil in in llic nj»j»< t p.nl of I.Ih; Htn;ill in!'' Iiii'-. 

( !(t'ni'pl:u-.ali<>'iiiM : 'II)'- ' lii' f" coil) j)l ion -, ;u'<; p^rilonil is, 
[)(;r(oni,l,ioti, jiihJ li lulu. 

IleUH — -diagnoHitt : L' ii;illy <;;i,sy. '\ \\(' <-,on'lilion niii I, Ix; 
(li(r<;n'nl (','d\)(',({\;i\\y IVom ;.M n<f;il (x i ilonil is, aculc ly|>li- 

lil,iM .-(imI jx rilyplilili,-, :i])j)' n<i icit i ;in<] <:o{)roHl,aHiH ; ocA'/dmm- 
silly (Vorn cJioN:/;!, ;rl r;in^iil;it Mdi of :) fl'>;il in^ kidrir-y, 

\'('Wa\ o;i,lrjiliiM, \(-.i.(\-('<i\\('.^ di;-|»l;ir( iiM nl, ol" llio iit^;nis, Jin(J 
ova,ri;ui ( iiffio»>;. 

[ (, is oflMi nior<' <liHi':iill lo r-<;r,oj_' nizo ;in<l lo<;;il(; l lio cniiHC. 
ol" I lie ol) :lj n<:( ion. VVIi<:n ob.-,l r'ur-J ion (liinior, rvjnojna.^ 
Hypiiilis^ is in lli*- hurcr jUirl, (>j Ihc. hirf/c iiil(Hliii.c., it may l»(; 

()y jor,l;il exam Inal, ion. Ohsl rn(;lioti in lliis [)a,r(- of 
(,Ih' ()0W';I will |)(rntil llx- i ii I rof I ion of only a, small (juan- 
(,il,y of wai< j- or aii- [x r I' olnni. SonH-limcs only small 
<ai('ni;ila may Ix; nso<l in |);ili* nl vvlio atf iiM'Voiis of nMii'as- 
iJicnic, oi- vvlio aiv- nol, arcn - 1 ()nH<l lo siwJi i n j^f;l,ions, ev^n 
wlwn IJk i o is no oh- l i ucl ion. ^ .a -cs of ol)sl,fii<t(,ion in lli<; 
low<'i- |)ail, of lli<; la,»"^o inL<:stinc show an ahsctHM; of" indi- 
canniia. In sn^'li <;asf!S llu' sym[)joms of ileus come, on laler-, 
ili(a'(! is < (»ii idei :il>lc meleoi i - III, an<l l liefe is nol, so ^Tcal, 
(;<>lla,|)S('. 

WliCM I, lie ol>sl niel ion i- in /(jiiiiiini <)V iijiprr par/ oj 

t/w, Ucn/m, IIh'.vc ly. ently vomilinji ol" l)ile(nol. sicreoiaeeon 
H(id(l(tii colla|)H(;, and a,l>:,en<'e of ^'eiHiral disli'til ion of I lie 
aJxIomcn. Indi^;an is ah-eni li om I lie urine, I lie : ;inie as 
vvIkmi IIh! ol)HinH;l,ion is in I lie reeliiin. The local i(»ii and 
(ifiaraoter of tlio pain may he deee|»live, hiil <)l"len will jj^ivc a. 
(jhif! to IIk! lo(!al,ion of I he o! )sliiiel ion. 

PrognOHis : ])(;|)eiids upon I he cause, w helhef I he occlusion 
is (JompkiU;, and (Ik; condilion of I he palieni,. In severe 
(;aH(iK lJi(! |)ro^»;nosiH is ha.d, aii<l e\( ii in cases less severe Ihe 
mortidity is hieh. 

Ileus — treatment: An nncoi.iplienlcd fjccal ohsl rncl ion 



ENTEROPTOSIS. 



223 



may be relieved by purgatives. In other cases all pur- 
gatives may do harm. Intestinal irrigation not only cleanses 
the bowel^ but may relieve strangulation before the for- 
mation of adhesions. Rectal injections often suffice to re- 
duce a volvulus or intussusception. The introduction of 
air into the bowel increases peristalsis and causes disten- 
tion of the intestine, but does not remove the contents so 
well as when water is used. Repeated lavage of the stomach 
may relieve the symptoms by lessening the tension on the 
intestine, and has been reported to effect a cure by exciting 
reflex movements in the intestine, in cases of an incarcerated 
convolution, intussusception or volvulus. 

Opium in suppositories, or morphine subcutaneously, may 
be given to overcome peristalsis and pain. While administer- 
ing opiates the physician should not underrate the gravity of 
the case. 

Intestinal convolutions distended by gas may be relieved 
by puncture, under strict asepsis ; but, especially in cases of 
intestinal paralysis, there is danger of some of the contents of 
the intestine getting into the peritoneal cavity through the 
puncture and causing peritonitis. Sometimes the paralysis 
caused by the passage of foreign bodies may be relieved by 
massage and electricity. Excessive thirst may be relieved by 
rectal injections of water and permitting the patient to drink 
all the water he wants, with lavage of the stomach. Infusion 
of salt solution may be called for. 

Many cases can be relieved only by surgery. When an 
operation is decided upon, the earlier it is done the less will be 
the danger. A primary enterostomy or colotomy should be 
made, if the patient is not in condition to undergo a more pro- 
longed operation, and a secondary operation may follow when 
the patient is in better condition. 

ENTEEOPTOSIS. 

The term, enteroptosis, is used to indicate a descent or dis- 
placement of any of the abdominal viscera, as well as a down- 
ward displacement of the intestine. A descent of the trans- 
verse colon, coloptosis, is thciinost frequent intestinal displace- 



n/.si'JASKs ()/'■ 'nil': ohj^ans oi' dkjks'j/on. 



men I. I *i())iiinrtit c;!!!-' - ;i ic roi i - 1 1 p.-i t loii nti'l violcnf. cxcvtAon. 
'I'licrc, ;i !■(• l r( (|H( iit I \ cni;!' !:! I I'di i iid i^;f.st.i(j|). \'j\\\( ](>\t\()~\.~ 

i- iiio I lie*! iK iiL ill ol" ;i,i);x;iii i;A jukI ]icijru.slJif;iii;ij wliicli 

roiwlil loll il u</jrViWdi('.H, 

'I lie d /gnosis tii;iv \><' ni;i/K; l^y p^inMissioii of llic \>(>\\c\ nflc.r 
il i (ii-h'ii(|''<l w it II ;iir. 

Treatment; (-ill |'.,r tli'- rdicl" of ronslJ j);i,t ioji, ndciiiioti to 
( lie ?n'ii''i;il li' ;illli, ' I c ' i.i 1 1 \ I lie t r' ;il,iiir;nt of Jinu-mi;! ;iii'l 
iiciir;i I liciii:i, ;iimI lli'' 1 1 1 1) )orl of 1 1 m; ;i I ^'I'diH'H [>y ;i w f ■! I -li 1 1 1 ii^i; 
l);iinl;i;j/; or ii|)j»orl( i'. 

HEMORRHOIDS ' Piles j. 

Etiolo^^y : I I''iiiorrlioi<l - occur moM frc(jiiciil I v from iliirly 
lo (iflv \c;ir- ol" ;i;_'c. I Iciiioirlioi<l- iii;iv l)c c;iii~c(| hv iiiiy- 
( liiii;.!' u liicli iiilcrlcrc- wil II tlic rcliirii of Mood from tlic licm- 
()rrlioi(|;ii vein.-. I 'rom i iicn t c;iii-c- ;n"c cimi-I i|);il ion, ol>,~,t I'lic- 
lioii ol' (lie |)orl;il ci rcii l;i t ion f ci rrlio,-I,-; of Mm- I i \ cr j, (;1i ron i(; 
j)|-0(;|.i lis, :-l rict lire of I lie reeliim, peU ie or :ilj(loiiiiii;il <i-rovv(liS 
or I nmo»"s, |)re<j ii;inc\ , en l;i r^'cment of t lie pro-f'ile, ;in(l <lise;iS('S 
of the lie;irt :iii(| liiii!,'.- tli;il m;iy c;iii~e coii'jc-l ion of (lie lieiii- 
orrlioi(l;il \'eiii- \>y i iit cilerence \\i(li (Ik; <'irciil;i( ion of (lie 
hlood. 

Symptomatoloj^y : Tlie |);i(ieii( feels ;is if :i. forcjen Ixnly 
were in (lie rrctiim, wliich c;iii-f Idirniii'j; ;iii(l sm;i r( injr, ofleii 
|»;uii("iil < lefee;i I ion, sol i lel 1 1 1 le-, |»;iiiifiil 1 1 1 ic( 1 1 ri ( ion . Ill c'ises 
of I iilcriial, li(iii<)rrli(>i(ls (here iii;i\' he :i iiiiieoiis or miieo j)iirii- 
len( (lisch}ir<i;(!, somedmes iiiixeij with hlood. 

Diagnosis: lv\lerii;il lieiiiorrlioi(fs .iii;iy he i-evenled hy in- 
spcelion; iiilerii.ii lieniorrlioid , hy iiispeelion (hroi|M|i 
r(!c(;il speeuhnii oi- hy di^iliil ex;imiii;i( ion. 

Prognosis: Asa i-nle<r()()d ;is f;ir ;is life is eoneei'iied. Ik*:irely 
(he hemorrhoids ni;iy hecMHiie si r:i ir:jii hit ed or o;i niireiioiis. Iv(;- 
l;i|>ses ;ire fre(jiieii(,, ex(;e|)(, when (|ioroii<_'h siir<jie;il (rendiieiil 
is resoi'(ed (o. 

Hemorrhoids — treatment: /\s f;ir :is possihlc ihc (^Jiiis(i 
siionld he remoN'ed. ( 'oiis( i|);i( ion should he relieved: cxc;!*- 
(^i,s(^ shoidd h(! prciserihcd for tJi(! iiidoIeiH :iiid (hose en<;n«;('d 
ill se<len(:iry oeeii piil iotis. 'V\n\ jKitieiif should jihsluin IVou) 



INTESTINAL NEOPLASMS. 



225 



irritating food and drink, such as strong spices, alcoholic 
drinks, strong coffee and tea, acid articles (pickles), and food 
that contains much material that will be left as a residue in 
the intestine. Upholstered chairs and feather beds are to be 
avoided. After defecation the anus should be sponged, best 
with a weak solution of carbolic acid or some antiseptic, and 
dried with lint. 

For symptoms of irritation, especially after excoriations, 
the application of an ointment of vaseline, lanoline, or cocoa- 
butter, containing morphine, extract of belladonna, or cocaine, 
may give relief. The hemorrhoids may be touched with a 
2 per cent, solution of cocaine, or a 1 per cent, solution of ni- 
trate of silver. Inflammation may be relieved by ice-water 
or ice bags, poultices, or hot baths. 

Pain may be relieved by ointments (unguentum gall^e cum 
opii or suppositories of opium or morphine and atropine. 
Hemorrhage may call for the administration of calomel and 
bicarbonate of sodium, or the local application of ice plugs, 
tampons, or injections of hot water, and astringent solutions, 
tannic acid, alum, acetate of lead, or nitrate of silver. Prolapse 
and strangulation or very great discomfort call for the inter- 
vention of surgery. Injections of carbolic acid, 1 : 3 of glyc- 
erin, gtt. v into each pile, may be repeated at intervals of a 
few days. These injections may be preceded by injections of 
a 1 per cent, solution of cocaine or the Schleich fluid. Care 
should be taken not to make the injection into the cellular 
tissue, because of the danger of abscess. 

INTESTINAL NEOPLASMS. 

Carcinoma is the most frequent intestinal neoplasm, but 
does not occur as often as carcinoma of the stomach. Most 
cases occur from forty to sixty years of age. Only one-seventh 
of cases occur before thirty (Maydl). From an examination 
of the statistics regarding the location of carcinoma of the in- 
testine, Ewald found the rectum involved 874 times, the large 
intestine 148 times (the transverse colon 12 times), the csecum 
including the appendix 64 times, the ileum 26 times, the duo- 
denum 19 times, and the jejunum 17 times. 
15- p. M. 



22G i)fS/'JAS/':s of tiii': oiujanh of diofstion. 



Symptoms: Often carcinoma may exist some time before 
symptoms are wot'icAtd. The most characteristic symptoms are 
t\\(i [XHMiliar (McJuixidy the {)resence of Ji tuni/jr, ma/rudriiicyn, 
o/jstrudion of tlw, hoincl. Tlie ol>-1 riict ioii of tlie bowel 
may (lisapp(;ar iitidor treatment to reappeai- again later. I'he 
condition is chronic Other symptoms will depend u))on tlj(i 
location of the carcinojiia. Som(;times a tumor may not be 
detected. 

Diagnosis: In the presence of a complete array of symp- 
toms, (.'Specially cachexia, tumor, and intestinal obstruction, 
the diagnosis is easy. Sometimes a [)ie(5e of the neoplasm may 
be removed, through a rectal speculum or endoscope, or 
through an incision, and examined microscoj)ically, to uvAnt 
the diagnosis absolute. Jnt(,'stinal carcinoma should be dif- 
fer eiiduiUu I from tuberculosis, syphilis, dysent(;ry and typhoid 
fever, carcinoma of the pylorus or of the gall-bladder, pan- 
creas or omentum, (!(;hinococcus of the omentum, retro))eritoneal 
neoplasms, neo})lasms of the uterus and its adnexa, intestinal 
con(;retions (gall-stones, f;eces;, appendicitis, and tumors of 
the kidney or sj)leen. 

The prognosis is unfavorable. Such ])atients may live for a 
number of years. The; dui'ation ol" lile is usually longest 
when the carcinoma is situated in the re(;tum. 

The treatment is surgi(;al, and should be i"(;sorted to as soon 
as a diagnosis is made. The results are not so good after the 
formation of metastases ov a(Jhesions. Often marked im- 
provement follow\s colotomy. 

Sarcoma and lymphosarcoma of the intestine are rare. TIk; 
most common site is the siiiall intestine. Thei'e is a marked 
tendency to metastases, and the course is more raj)i(l than in 
carcinoma of the int(;stine. 

Among the benign neoplasms of the intestine are adenomata, 
fibromata, lipomata, j)apillom;it:i, angiomata, myomata, fibro- 
myomata, myxomata, and iibro-in yxomata. 

Most important are the iv./(.<// na/ />o/7//>/, tumors having a 
pedi(;le, which may cause intestinal obstru(;tion. In the small 
intestine they may cause invagination. Jlectal polypi may be 



ACUTE PERITONITIS. 



227 



detected by digital examination. All such tumors may cause 
diarrhoea, with the discharge of mucus, pus, or blood, or in- 
testinal obstruction and hemorrhage. 

DISEASES OF THE PERITONEUM. 

ACUTE PERITONITIS. 

Etiology : Acute inflammation of the peritoneum is caused 
chiefly by bacterial infection, most frequently by the bacillus 
coli communis, streptococcus pyogenes, staphylococcus pyo- 
genes aureus, citreus and albus, sometimes by the micro- 
coccus pneumonise croupos^e, bacillus lactis aerogenes, bacillus 
typho-abdominalis, and the proteus vulgaris. These bacteria 
may gain access to the peritoneum through solutions of con- 
tinuity (perforating ulcers, wounds) of the stomach, intestine, 
or abdominal wall, or through the intact walls of the stomach, 
intestine, or other abdominal or pelvic organ covered by peri- 
toneum, when injured (trauma) ; or through extension of in- 
flammation of abdominal or pelvic organs (appendicitis, 
genito-urinary diseases). 

Peritonitis, due to the micrococcus pneumoniae crouposse, is 
found most frequently in girls. When localized, the process 
is found in the pelvis. Boulay found the micro-organism in 
the uterus, which would seem to indicate that the channel of 
infection of the peritoneum is from the uterus, through the 
lymphatics or tubes (F. Brun). 

Pernice produced peritonitis experimentaUy, in rabbits and 
guinea-pigs, by injecting chemical substances (concentrated 
mineral acids, acetic acid, phenol, nitrate of silver) into the 
peritoneal cavity. Sternberg failed to produce peritonitis in 
rabbits by the introduction of sterilized powdered glass into 
the abdominal cavity. 

Other causes of acute peritonitis are general septicsemia, 
miliary tuberculosis, malaria, dysentery, nephritis and suppu- 
rative inguinal adenitis (Fitz). 

Symptomatology : The principal symptoms of acute peri- 
tonitis are abdominal jxmi and tenderness, constipation (some- 
times diarrhoea), nausea, often vomiting. Usually the tern- 



228 



DISEASES OF THE ORGANS OF DIGESTION. 



perature is high and the facial expression anxious. Thirst is 
often distressing. There is singultus. The abdomen is at first 
retracted, later distended and tympanitic. The abdominal 
muscles are firmly contracted. Respiration becomes largely 
or altogether costal. The pulse is rapid, small, and wiry. 
Frequently there is retention of urine. Sometimes there is 
collapse . 

Pain and tenderness may be absent, especially in septic 
(puerperal) peritonitis. Sometimes the peritonitis is limited 
to a part of the abdominal or pelvic cavity to which the 
symptoms are confined, constituting a localized peritonitis. 

Complications and sequelae of peritonitis: There may be 
tympanites, from paralysis of the bowel ; obstinate vomiting, 
probably reflex through the pneumogastric nerve ; retention of 
urine, through extension of inflammation from the peritoneal 
covering to the muscular wall of the bladder ; bronchitis, 
pneumonia, pleurisy, or strangulation of the bowel. 

Diagnosis : The abdominal pain and tenderness, board-like 
rigidity of the abdominal muscles, and constipation, form a 
characteristic group of symptoms of acute peritonitis. More 
difficult to diagnosticate are the cases in which abdominal pain 
and tenderness may be absent. Acute peritonitis should be 
differentiated from obstruction of the bowel, acute hemorrhagic 
pancreatitis, hysterical peritonitis, gall-stone and renal colic, 
and subphrenic abscess. 

The prognosis should be guarded. 

Acute peritonitis — treatment : If possible, the cause should 
be found and removed, if necessary by the intervention of 
surgery. 

The medical treatment consists in the relief of pain and 
vomiting by the administration of opium internally or mor- 
phine hypodermatically. Turpentine stupes and mustard 
plasters may be applied to the abdomen. Some cases may be 
relieved by high rectal injections, which may contain turpen- 
tine and milk of asafetida. Alcohol, best in the form of wine, 
whiskey, or brandy, is sometimes useful. 

In the absence of vomiting, food may be given by the 
mouth; but usually it is best to give the stomach a rest. The 
patient may be sustained for a few days by nutritive enemata. 



TrBEECTLAB PEEITOyJTIS. 



229 



The judicious use of saline purgatives is often of very great 
value. 

> - : ;se may be found and removed by an ex- 

ploiu: y ::: >: A- in sid many other conditions, when an 
operation is : earlier it is performed the better are 

the chances fur icC jVciy. 

TUBEBCULAE PEPJTONITIS. 

Definition : An infection of the peritoneum by the tubercle 
bacillus. 

Etiology : The tubercle bacillus infects the peritoneum 
most frequently by direct extension from the intestine, next 
in frequency from the female genital organs. The disease 
occurs especially in early adolescence, but infancy and old age 
are not exempt. 

Symptomatology (see Symptomatology of Acute Peritoni- 
tis) : Usually the symptoms of tubercular peritonitis are not 
so acute, and the course is more chronic. Abdominal disten- 
tion and rigidity, emaciation, and the streptococcus fei-er-curve 
are present. There may be symptoms on the part of the organs 
primarily affected, especially the lungs, intestine, and genital 
organs. 

The temperature may be subnormal for days at a time (Osier, 
Musser). Sometimes tuberciilar nodules are recognized by 
palpation, especially upon vaginal or rectal examination 
( Heger). There may or may not be ascites. 

The disease n: v . r rinue for months or years, or early 
show the sympt'i : - : : liary tuberculosis or acute peritonitis. 

Diagnosis: S' : - - - bacilli may be found in the 

asr-itie fluid, O:: . . : . :: jO of tuberculin will clear up 

a doubtful case. 

Ditferential diagnosis has to do chiefly with chronic peri- 
tonitis (not tubercular) and cirrhosis of the liver. 

Prognosis: Some cases may be rescued only by operation 
and the exposure of the peritoneum to the air. Cures have 
resulted from puncture and aspiration, and sp<:)ntaneously. 
Many cases terminate favorably under medical treatment. 

Tubercular peritonitis — treatment : Alanv cases mav be res- 



230 DISEASES OF THE ORGANS OF DIGESTION. 



cued by the use of tuberculin R, climatotherapy, cod-liver 
oil, and massage. Laparotomy, with the removal of the 
primary focus in the intestine or female genital organs (Fallo- 
pian tube), sometimes gives the best results. It may be nec- 
essary to make repeated laparotomies. Aspiration and the 
injection of air and other substances into the peritoneal cavity 
have been unsatisfactory. 

CHRONIC PERITONITIS. 

The most frequent form of chronic peritonitis is tubercular 
peritonitis, which has already been discussed. 

The etiology of chronic peritonitis, aside from tubercular 
peritonitis, is obscure. Exposure to cold has been invoked as 
a cause, as have also the causes of acute peritonitis in the 
presence of sufficient resistance to prevent an acute attack. 
Localized clironic peritonitis is most frequently due to sub- 
acute pelvic inflammations in which the irritation is not suf- 
fi(;ient to produce an acute peritonitis. Sometimes cases may 
be caused by repeated paracentesis abdominalis (tapping). 

Symptomatology and diagnosis : The symptoms resemble 
those of acute peritonitis, but are, as a rule, less intense. The 
distinction between tubercular peritonitis and peritoneal neo- 
plasms is sometimes impossible. Most important is the dis- 
covery of the cause. 

The prognosis is usually good. The greatest danger arises 
from complications, especially strangulation of the bowel and 
pressure upon important abdominal organs. 

The treatment is the treatment of peritonitis in general 
(see Treatment of Acute Peritonitis). Ascites may be relieved 
by paracentesis. 

PERITONEAL NEOPLASMS. 

Carcinoma rarely occurs in the peritoneum primarily. Sec- 
ondary involvement of the peritoneum is not uncommon. 
The treatment is purely surgical 

Hydatid cysts occur most frequently in the abdominal 
organs, but may occur in the peritoneum. Diagnosis often 



ICTEEUS. 



231 



rests upon exploratoiy incision. Aspiration is dangerous. 
The treatment is surgical. It is better to remove the cyst 
without puncture. 

Other tumors of the peritoneum are sarcoma, lipoma, and 
fibroma. More rare are myxoma, endothelioma, hemangioma 
and chylangioma, papillary cystoma, dermoid and teratoid 
cysts. 

The treatment of neoplasms, when active treatment is de- 
manded, belongs to surgery. Otherwise the treatment is 
largely symptomatic. 

DISEASES OF THE LIVER. 

ICTERUS f Jaundice . 

Icterus : Jaundice is a yellowish color of the tissties and 
fluids of the body. 

Etiology : Icterus may be caused by anything that inter- 
feres with the flow of bile. Such interference with the flow 
of bile may be caused by occlusion of the bile-ducts through 
swelling of the mucous membrane of the ducts, the presence 
of inspissated mucus, the impaction of a gidl-stone, or by the 
pressure that may be caused by cancer of the stomach, liver, 
])ancreas, omentum ; or by sarcoma ; or by the cicatrization of 
an ulcer in the duodenum or bile-ducts, or by abdominal 
tumors, vertebral caries, aneurism, etc. 

Symptomatology: The skin and mucous membranes present 
a change in color varying from a ligJd //(Uoirish tinge to a darJ: 
yelloir. Itching, pruritus, is tisually noticed after jaundice 
has existed for some time, but may even precede the appear- 
ance of the change in color. There may also be various 
cutaneous eruptions. 

There is liif< rji rriirr irifj, infestinal digtstioii and ahsorptioii. 
Fat appears in flu: stools in large amounts. The fieces are 
pcde, from the presence of fat and the absence of bile. The 
absence of the normal stimulus of the bile upon the intestine 
results in a lessened peristalsis and consec^uent constipation. 
The absence of the antiseptic action of the bile permits 
abnormal fermentation and putrefaction of the fseces and 
causes meteorism. 



2.32 



DISEASES OF THE ORGANS OF DIGESTION. 



The secretions and excretions, urine, })er.s[)ii'ation, milk, 
sometimes the sputum, may contain bile-pigments. 

The presence of bile in the blood, chol^emia, causes aalo- 
intoxication. The pulse-mte is lowered (bradycardia), but in 
long-continued cases of grave icterus the pulse may be normal 
or quickened (tachycardia). Sometimes the j)ulse is irregular. 
'J'he 'aaniber of red hlood-corpuscles is reduced, especially w hen 
icterus has existed for some time. 

'J'he feniperature is subnormal, unless elevated by some 
cause other than the icterus. Long-standiuL'^ f-nsf- may show 
hemorrhages from the mucous membranes, c-jx ciail}- epistaxis, 
gastrorrhagia, and enterorrhagia. 

Hie cliief 'nervous sijmptoms that may occur are delirium, 
coma, convulsions, muscular tremors, and paralysis of the 
sphincters. Often the patient is in a typhoid condition. 

Sometimes there is a l)itter taste in the mouth, and often 
the tongue is coated. 

Diagnosis: In light cases the change of cohjr may be 
observed in the conjunctivte as a slight yellowish tinge. In 
marked cases the yellow color of the skin is obtrusive. 
Bile-pigments may be detected in the urine. For tliis pur- 
pose various tests have been proposed. 

Graelin^s test consists in floating a layer of urine u])on 
nitrosonitric acid, when at the point of contact llioc be 
observed a distinct green color, representing the oxidation of 
bilirubin into biliverdin. Other colors may be present, but 
are not indicative of the presence of bile-pigment, llosenbach 
has modified this test by filtering the urine and placing upon 
the filter-paper thus used a drop of fuming nitric acid, wlien 
the color will appear as above. V. Jaksch remarks that the 
only caution to be observed in this modification is that the 
filter-paper must be pure and white. Pure white blotting- 
paper may be used and is quite satisfactory. 'J he blotting- 
paper is soaked with the urine and a drop of the acid added. 
The green color forms a distinct ring. 

A simple test suggested by Marechal consists in adding to 
the urine a few drops of the tincture of iodine. An emerald- 
green color indicates the presence of bile. 

The bile-acids may be detected by Fettenkofer^s test, best as 



GALL-STOSES. 



233 



modified by Strassburger. A piece of cane-sugar is dissolved 
in the urine, with which a piece of blotting-paper is then 
mofetened. After drjingj this is touched with pnre concen- 
trated sulphuric acid. A positive reaction consists in the 
development, at the point of contact, of a carmine-violet- 
purple color. 

Icterus should be cliffermtkdecl from Addison^s disease^ 
cachexia, and a normal jellow color of the skin. 

The prognosis is that of the disease causing the icterus. 

Icterus — ^treatment: As far as possible^ treatment should 
address the underlpng disease, usually catarrh of the bile- 
ducts, gall-stones, syphilis, malaria, or carcinoma. 

The did should consist of articles that will not irritate 
the liver: milk, soft-boiled ^gs, bouillon, meat soups, and 
thoroughlv cooked fruit. Alcoholic beverages and foods con- 
taining fat should be withheld. 

In the waj of medimne.% the salicvlates, salol, phosphate of 
sodium, benzoate of sodium, benzoic acid, calomel, and hydro- 
chloric acid are useful. In some cases hepatic stimulants 
may be used, especially podophyllin, jalap, and colocynth. 

Among the mineral irater^ in common use are Carlsbad, 
Vichy, Ems, Belters. H: :: ^ rn, Saratoga, and for some cases 
]Marienbad, Kissengen, and H rnb ircp. 

The salicylates not onl^ acr : n:> :DtTcally, but also increase 
and liquefv the ^. : Il~ :--ated ox-gall may be 

given internally : ~ _ . e an 1 anrl-eptic, or fresh ox-gall 
may be used in enemata. Large enemata of hot water 
(Bouchard) have been recommended in cases of threatened 
uremia and may l)e of value in cholgemia. 

GALL-STONES c::::e::this,5:? ; Biliary LitMasis). 

The concretions : 1 ' . v :1-V: . / and hiliary pa.^ 
mges vary in size, s r, and composition. The chief 

constituents are chole-r L inj bile-pigment (bilirubin, associated 
with biliverdin, bilicyanin, and bilifuchsin)^ and salts of lime 
and magnesia. The nucleus is sometimes a foreign b(xly 
(bacillus coli communis ; mercury). The stones are frequently 
laminatecL Usually they are feceted. 



2:m i)isi':ASh:s of tiii<: oroans of ij/ofstiom. 



Etiology: Al^oul, t wo-Uiifls of tlio casos occur in women. 
OdHctH iivc, ffiorc fVc(jtif iil ly ciiconnUtvad after forty, rarely iirifler 
twenty, alllioii^li gall-Htones liavo been found in tlie new-horn. 
( 'onditions vvliieli interfere witfi the How of fiile, sedentary 
hiii)i(H, oKI a^e, [)ad liygiene, diafK;leH, carcinoma of the stomach 
and hver, are (iredisposin^ causes. 

Mor^aj^rii has ohserve^l tliat gall-ston(?s and kidney-stones 
are frecjiiently found in the same individuaL Patients witli 
^all -stones are o("tcn suhjects of ohesity, rlieumatism, gout, 
Jitliaitnia, and alheroma. 

('a(ari"hal inflajnmation of the l>ih--diicts may \>(t a [>re- 
dis|)Osing cause, and th(; choh;slerin may |>reci[>itated on the 
necrosed e[)ithelium. It is possit)le that ty[)}ioid fever may 
phiy a v<)\(i in etioh)gy, and many times cases have been attrib- 
uted to the drinking-water. Gall-stones Iiave be(;n observed 
more fre^juently in some coiuitri(js f Hanover, Sweden, llun- 
garyj thari in oth(;rs (flolhind, r'inlandj. 

Symptomatology: Calculi in tin; gall-bladder may |)roduc(; 
no symptoms. Post-mortems show gall-stones in about ouf - 
tenth of all cases, most frequently in the femah; sex. The 
most obtrusive symptom is gall-stone colic. An over- 

distended gall-bhidder may be painful. The attack of gall- 
ston{; colic begins with a feeling of discomfort, which gradu;illy 
iticreases to absolute, often ex(;ru(;iating, pain, in the right 
hypochondrium or epigastrium. Tlura in interferencr, with di- 
(/rdion, H(>nuih(i(iH vorihili/nr/. Often the patient complains of 
pain at the angle or inner margin of the scaj)ula. Tlien; are 
ohdlpaU.Ofi and h/m'pan.i//'.s. There is a slight rise of tanpcrd- 
liu-c^ ^yy'-y.)J)'' v. IIhiujUii llicrc -Ih no icIcruH. As a rule, 
gall-stones do not cause (;oli(r, (ixcept when there is im[>action 
of the stone in I ho cyst ic duct. Wh(;n the gall-bladd(;r is 
enlarged it may be felt as a liimor. 

Diagnosis: Gall-stones should be dilfenaitiated es[)ecially 
from ulcer of the duodemim and idceration or mahgnaiit dis- 
eas(! of th(! j)ylorus, hej)atic carctinoma, and obstructions of lh(; 
bil(,'-ducts from other causes. 

Prognosis: The duration of an attack of I>iliary colic due to 
gall-stones is usually three lo six days. i^'rerjiient recurr(!nce 
is the rule. The advan(;(;s in surger)' hav(; made the oiillook 



GALL-STONES. 



235 



much more favorable. Surgery may give a mortality not ex- 
ceeding 5 per cent., except in cases of jaundice and malignant 
disease. The prognosis of malignant cases is bad. 

Prophylaxis : High living, rich diet (brains, yolks of eggs), 
and stimulants (ale, porter, wine) should be avoided. The 
use of tight-fitting waistbands and corsets should be aban- 
doned. Bicycling and horseback-riding are forms of exercise 
highly recommended. In the way of medicinal prophylactics, 
salicylic acid, cholate of sodium, the sulphate and phospliate of 
sodium an hour before meals, deserve mention. 

Gall-stones — treatment : Pure olive oil, a wineglassful at 
bedtime every night, may do good in some cases. If necessary, 
the oil may be substituted by glycerin. Sometimes the sali- 
cylate of sodium may be of value. Sulphuric ether and chloro- 
form have been used ; they probably act as antispasmodics 
rather than as solvents of the calculi. Durande used a mixt- 
ure composed of three parts of sulphuric ether and two parts 
of oil of turpentine, a drachm each morning. Graham suggests 
that gtt. XX three times a day would be better tolerated by the 
stomach. Large quantities of water, hot water with or without 
bicarbonate of sodium, 5j-ij : Oj, or mineral water, especially 
Carlsbad and Vichy, are often beneficial. Sodium sulphate 
has been recommended, sj-ij, taken before breakfast in a bitter 
infusion, with sodium bicarbonate, gr. xx-xxx at bedtime 
(Harley). For the indigestion caused by the cutting off of 
the bile from the intestine, ox-gall, cholate of sodium, acetic 
acid, and citric acid have been recommended. 

Pain may call for the hypodermatic use of morphine, to 
which belladonna or atropine may be added. Sometimes re- 
lief is obtained by the local application of heat, or better by 
the hot bath. Severe pain may demand chloroform or ether. 

Surgery offers the most hope for absolute cure. The opera- 
tion to be selected will depend upon the conditions present in 
the individual case. Among the operations commonly per- 
formed for gall-stones are : cholecystostomy, in which the gall- 
bladder is opened, the stones removed, and the gall-bladder 
stitched to the abdominal wall; cholecystectomy, complete 
removal of the gall-bladder ; cholecystenter ostomy, in which 
a direct communication is established between the gall-bladder 



236 DISEASES OF THE ORGANS OF DIGESTION. 



and intestine ; choledochotomy, choledocholithotomy , in which 
the common duct is opened for the removal of a gall-stone. 
Operations less frequently performed are cholecA/stendysis, re- 
moval of stones from the gall-bladder by incision, closure of 
the incision by suture, and return of the gall-bladder to the 
abdominal cavity ; choledoGholithotri'psy , in which the gall- 
stone is crushed in the common duct; and puncture of the 
gall-bladder. Calculi have been forced from the common bile- 
duct by external pressure, a procedure not devoid of danger, 
especially of rupture. 

ACTIVE HYPEREMIA. 

Hypersemia of the liver occurs physiologically during diges- 
tion, and may become excessive after indulgence in food of an 
irritating nature (alcohol, spices), or which may cause intes- 
tinal fermentation. Persistence in such indiscretions may 
cause a permanent pathologic hypersemia of the liver. 

Hypersemia of the liver is common in the infections, espe- 
cially typhoid fever, malaria, and dysentery. Gout is a fre- 
quent cause. Some cases are due to syphilis. 

Among the toxic causes are alcohol, carbonic oxide, mer- 
cury, carbolic acid, phosphorus, arsenic, nicotine, etc. 

Tropical hypersemia of the liver is probably largely due to 
infection. Some cases are attributed to nervous causes acting 
through the vaso-motor nerves. 

Hyperemia of the liver — symptomatology : The onset may be 
gradual, with a feeling of tension in the epigastric region and 
dyspeptic symptoms. Usually the symptoms begin rather 
suddenly, with a slight chill and fever followed by pain and a 
feeling of tension in the region of the liver, radiating to the right 
shoulder. Dyspeptic symptoms appear early, sometimes before 
there is pain, and become pronounced. There are nausea, 
vomiting, and diarrhoea. Slight icterus appears in two or three 
days, and may become severe. The fceces are colored (pleo- 
chromatic). The urine is reduced in quantity, with high 
specific gravity, contains bilirubin or urobilin, and an in- 
creased amount of urea, 40-50 grammes in the twenty-four 
hours. Severe cases may show some enlargement of the 



PASSIVE HYPEREMIA. 



237 



spleen. More prominent is the enlargemerd of the liver, palpa- 
tion of which is usually painful. 

Diagnosis : The chief diagnostic points are the severity of 
the symptoms, the elevation of temperature, the general con- 
dition of the patient, and the course of the disease. Most 
important is the determination of the cause, and the separation 
of active hypertemia from cirrhosis of the liver and ab-cess 
of the liver. 

The prognosis is usually goc>d when the cause can be re- 
moved. 

Hyperemia of the liver — treatment : Should first address the 
cause. The diet must be regulated, alcohol withheld, and gout, 
raalaria, or other infectious d'- - roperly treated. Usually 
a milk-diet is best. An inii:.. u ~c of calomel maybe fol- 
lowed by the iLse of saline purgatives or mineral waters. 
Carslbad and Yichy are recommended as watering-places for 
chronic cases. Cold is applied to the region of the liver, in 
the form of an ice-bag or cloths wrung out of ice- water. In- 
testinal antiseptics are used. 

PASSIVE HYPERiElMIA. 

Passive hyperemia of the liver is caused chiefly by obstruc- 
tion of the general circulation, which may be due to val- 
^Tilar disease of the heart, myocarditis, pericarditis, arterio- 
sclerosis, aneurism, marasmus, pleurisy, empyema, asthma, 
bronchitis, emphysema, or pneumonia. Alcoholism and the 
infections, especially malaria, may account for these causes 
producing passive hvper?emia of the liver in some individuals 
and not in others. Some cases are due to obstruction in 
the hepatic veins. 

Syinptomatology : There is erdargeraerd of the liver, sometimes 
with persistent pain, which may be increased by palpation. 
There may be anorexia , vomiting, eructations, and cmLstrpation 
alternating icith diarrhoea. Obstruction of the hepatic circnla- 
tion may cause hemorrhoids and hemorrhage from the intestine. 
Often there are ' ■ " > and the formation of the capjid Jledusre. 
The urine is d: . d in quantity, hisrh colored, of high 
specific gravit}^. and usually contains urobilin and tiroervthrin, 



238 DISEASES OF THE ORGANS OF DIGESTION. 



and in marked cases of jaundice pure bile-pigment. Urea may 
be diminished or increased with a diminution or increase in 
the vohime of urine voided. Uric acid and tlie chlorides are 
decreased ; the phosphates are increased. There may be gly- 
cosuria, sometimes albuminuria. 

The diagnosis, in the presence of enlargement of the liver, 
is easy when an etiological factor, such as a pulmonary or 
cardiac lesion, is obtrusive. 

The prognosis depends largely upon the cause, the condition 
of the patient, and the severity of the case. 

Treatment : A failing heart must be stimulated. A milk- 
diet should be adopted. In the way of medicines, calomel, 
the saline purga ives, and mineral waters are most important. 
Calomel and diuretin may be used as diuretics. 

Cases which resist other treatment may be subjected to para- 
centesis, repeated as often as necessary, from which very good 
results may be obtained. 

ABSCESS OF THE LIVER (Suppurative Hepatitis). 

Etiology : The principal causes are pyaemia, inflammation 
of the bile-ducts, dysentery, appendicitis^ suppurating glands, 
ulceration from gall-stones, suppurative pylephlebitis, umbili- 
cal phlebitis (in the new-born), tuberculosis, foreign bodies, 
and parasites. 

Tropical abscess in some cases depends upon the presence 
of the amoeba coli, but in many cases the amoeba may not be 
found. The pus-producers, especially the staphylococcus 
pyogenes aureus and staphylococcus pyogenes albus, are fre- 
quently present. It is supposed that alcohol, through the 
production of acute hypersemia of the liver, is a predisposing 
cause. Some cases may be due to toxins. The absence of 
micro-organisms may be due to their destruction by the liver. 

Abscess of liver — symptomatology : Symptoms may be absent 
or indefinite, or overshadowed by sepsis or trauma. 

The acute form, found especially in hot countries, begins 
with malaise, chills, and fever, sometimes remittent or inter- 
mittent, higher in the evening and at night. The region of 
the liver becomes painful, especially upon pressure, Avith a feel- 



ABSCESS OF THE LIVER. 



239 



ing of tension and weight. There are dyspnoea and cough, 
described by Galen as the hepatic cough, slight, dry, and 
hard. The cough is supposed to be due to an impulse trans- 
mitted along the phrenic and vagus nerves. There may be 
icterus and comiting of bile. 

The symptoms continue to increase for eight or ten days. 
Fever persists and there is profuse perspiration. Death may 
result, or at this time the abscess forms and there is a slight 
improvement in the general symptoms, with increase of the local 
symptoms on the part of the liver. 

In the subacute form, which is the most frequent in the 
temperate climate, the symptoms are less severe and the local 
symptoms of abscess come on more gradually. 

The chronic form shows the greatest variations in symp- 
tomatology. Some cases show about the same symptoms as 
the acute and subacute forms, but not so severe^ and the 
formation of the abscess is slower. 

With the formation of abscess the liver shows increase in 
size, and a tumor may be visible. When the abscess is super- 
ficial the thoracic walls may be oedematous. The liver-dul- 
ness extends farther upward than normal. Often there is 
pain radiating to the right shoulder. There may be jaundice 
(frequently absent), sometimes ascites (even more rare than 
jaundice). There is/ei-er as a rule, which varies in type and 
elevation. 

Examination of the urine shows at first an increase of 
urea. Later there is hypoazoturia (Semmola and GiofPredi). 

Diagnosis : Sometimes easy ; sometimes exceedingly diffi- 
cult. Malaria, typhoid fever, and tuberculosis must be ruled 
out. More difficult often is the diflFerentiation from hyper- 
semia of the liver, echinococcus of the liver, and neoplasms. 
Some cases may be decided only upon puncture or inci- 
sion. 

The prognosis depends largely upon the form of the disease, 
better results being secured when there is a single abscess than 
when there are metastatic abscesses. The prognosis of met- 
astatic abscess depends largely upon the primary disease. 
The prognosis should always be guarded. Spontaneous cure 
very seldom occurs. 



240 mSEASES OF THE ORGANS OF DIGESTION. 



Treatment is surgical. The medical treatment is symp- 
tomatic. 

CIRRHOSIS OF THE LIVER (Chronic Interstitial Hepatitis; 
Hobnail Liver; Gin- drinkers' Liver ; Contracted Liver j. 

Cirrhosis of the liver is characterized by general prolifera- 
tion of the hepatic connective tissue. 

Etiology : The most frequent cause is alcohol. Other toxic 
causes are lead, mussels (Segers), and spices and highly sea- 
soned food (Budd), gout and diabetes, rickets and dyspepsia. 
Among the infections syphilis, tuberculosis, and malaria are 
causes. Some cases are probably due to toxins, especially the 
toxins of typhoid fever, measles, and scarlatina. Senility is a 
cause of cirrhosis of the liver associated with arterio-sclerosis 
and endarteritis. Some authorities believe that cirrhosis of 
the liver may result from retention of bile. 

Adami found diplococci, sometimes resembling gonococci 
and sometimes appearing more like short bacilli, in the liver- 
cells and new connective tissue. Similar organisms were 
found by Adami in the Pictou cattle disease, an infective 
cirrhosis of cattle. 

As a rule alcoholic cirrhosis is found in middle life. Bar- 
low found cirrhosis of the liver, post-mortem, in a child 
eighteen months old who had received alcohol as food in the 
form of beer and gin. 

Cirrhosis of liver — symptomatology : The early symptoms are 
those of « ff astro-intestinal catarrh: eructations of gas, gastric 
pain, coated tongue, nausea and vomiting, and diarrhcea alter- 
nating with constipation. 

There are liepatic tenderness and pain radiating toward the 
right shoulder. The patient is pale, emaciated, and experi- 
ences early fiitigue. At first the liver may he larger than nor- 
mcd, but with the contraction of the cicatricial tissue the liver 
becomes reduced in size and the surface uneven (hobnailed). 

Ascites comes on gradually and is frequently the sym])tom 
that causes the patient to seek medical advice. The ascites 
may be due to peritonitis (Hanot). Usually there is enlarge- 
ment of the spleen, which often is difficult to detect. 



CIRRHOSIS OF THE IIVER. 



241 



The subcutaneous abdominal veins become dilated, especially 
on the right side, and there is dilatation of the capillaries 
along the margin of the ribs and around the umbilicus (the 
caput Medmoe), 

The urine may at first be increased in quantity, but soon be- 
comes scanty, high colored, and of high specific gravity. The 
reaction is strongly acid^ and urates are present in abundance. 
The amount of urea is decreased ; urobilin and uric acid are 
increased. Semmola has observed a constant inverse ratio 
between the amount of urea and urobilin eliminated. There 
are peptonuria, sometimes glycosuria and albuminuria, from 
passive congestion and cachexia. With great diminution in 
the quantity of urine there may be symptoms of toxcemia. 
Jaundice more or less marked appears especially late in the 
course of the disease. 

Hemorrhage is present in the majority of cases. Epistaxis 
is frequent. Hemorrhage from the gastro-intestinal mucous 
membrane, usually appearing as hsematemesis, may be so great 
as to be fatal. 

Fever may be present in acute cases, or may be caused by 
perihepatitis or catarrh of the bile-ducts. 

Diagnosis : The history of long-continued indulgence in 
alcoholic beverages, with the presence of the symptoms of 
gastro-intestinal catarrh and ascites, would lead to the sus- 
picion of cirrhosis of the liver. Confirmatory evidence would 
be furnished by physical examination. The liver is dimin- 
ished in size, the surface nodulated ; the spleen is increased in 
size, and there is cachexia. The surface-vessels are enlarged. 

Cirrhosis of the liver should be differentiated especially 
from pyelophlebitis, pyelothrombosis. thrombosis, hypertro- 
phic cirrhosis, diffuse chronic peritonitis, hyperaemia, amyloid 
liver, syphilis, carcinoma of the liver, and the simple atrophy 
of marasmus. Males are aflPected more frequently than females. 

Prognosis is unfavorable as far as ultimate recovery is con- 
cerned. The usual duration of life is one or two years, 
although in some cases with judicious treatment life may be 
prolonged for a number of years. The course may be ab- 
ruptly terminated by hemorrhage, pleurisy, bronchopneu- 
monia, or tubercular peritonitis, 
16— p. M, 



242 DISEASES OF THE ORGANS OF DIGESTION. 



Cirrhosis of liver — treatment : The cause, if possible, should 
be removed. Alcohol, spices, highly seasoned food, and coffee 
must be withheld. The diet should consist of milk, broths, 
farinaceous foods in moderation, cooked fruits and vegetables, 
except potatoes. Carlsbad salt is useful for the relief of the 
gastro-intestinal catarrh. 

In the treatment of ascites appeal is made to the diuretics. 
Digitalis may be given in combination with acetate of potas- 
sium. Hydragogue cathartics, compound jalap powder, gam- 
boge, and elaterium may be used. 

Sooner or later tapping (paracentesis abdominis) becomes 
necessary, and should be repeated as often as required. The 
withdrawal of the fluid must not be too rapid, or the dis- 
tended peritoneal vessels may rupture and syncope result from 
cerebral anaemia. 

Further medical treatment is purely symptomatic. 

Hypertrophic cirrhosis of the liver : This variety of cirrhosis 
of the liver occurs especially between twenty-two and thirty- 
five, rarely after forty (Graham), most frequently in males. 
Differing from the ordinary cirrhosis of the liver, hyper- 
trophic cirrhosis shows an enlargement of the liver, the surface 
of which remains smooth or is roughened only from a peri- 
hepatitis ; absence of ascites, except in the later stages, when 
it is usually caused by peritonitis ; absence of enlargement of 
the subcutcmeous abdominal veins, except late in the course of 
the disease ; a good appetite, only slight emaciation, and a 
somewhat lessened secretion of urea. The duration of the 
disease is usually longer than in the case of ordinary cirrhosis, 
frequently eight or ten years. The fseces contain bile, in the 
presence of icterus. 

Treatment: The diet should be the same as in ordinary 
cirrhosis. Constipation must be overcome, best with the mild 
salines. Intestinal decomposition calls for calomel, hydro- 
naphthol, and salol. Diuretics and the ingestion of milk 
increase the action of the kidneys and thus eliminate the 
poison that accumulates in the body through the disability of 
the liver. 



ACUTE ATROPHY OF THE LIVEE. 



243 



Simple atrophy of the liver occurs in age and mara-mn?. is 
not a disease^ and is not accompanied by characteristic symp- 
toms. 

ACUTE ATEOPHY OF THE LIVER Acute Yellow Atrophy ; 
Icterus Gravis . 

An atrophy of the liver characterized by destructinn of the 
hepatic cells and severe Jaundice. 

Etiology : The disease is rare. Women are mr)re frequentlv 
affected than men. The di-ea-e occurs frequently durino- 
pregnancy. It may occur at auy a^'c. fr^im les- than a year 
to over sixty, but is mo-t cummnii l)etween t^veut^• and thirty. 

Symptomatology: The tai-lu siiuii,f>iin.< are thn-e nf -yr/.v/z-o- 
intestiiio.l cfAtni-rh: loss of appetite, nau-ea. vomitiuo\ constipa- 
tion, pain and tenderness over the liver: later, j'luiidicc in 
two-thirds of the cases, beginning in the face and gradually 
extending over the body. Sometimes there is an initial rigor. 
There may be general weakness, pains in the muscles, a 
tremulous tongue, and epistaxis. Later tliere are cr//v//r/r- 
asthma and an ir r'rjiilftr pidsc vifli iiii-i'>ns^ '1 f>:nsion. Later 
marked nervous ^//'njjfoins supervene — re-tle-->ness. delirium, 
coma, irregular breathing. Avhicli becomes stertorous, and 
death. 

The liver, which at first may show some increase in size, 
becomes r/rtfifli/ nfrnjjjii'd, witli diminished dulness from 
below upward and from left to riulit. r)eatli may -upervene 
before there is marked atrrqihy of tlie liver. Sometimes 
atrophy of the liver cannot he detected when tliere i- an 
accompanying hyperplasia of the connective tissue. 

H^niorrhages occur in more than half the cases, usually in 
the form of hsematemesis. 

Diagnosis : The early symptoms are those of catarrhal jaun- 
dice. The characteristic symptoms begin later : severe jaun- 
dice, hemorrhaLi^e. and nervou- symptom-. Leucin and tyrosin 
are usually to be foun;] in the urine. The ol)jective symptoms, 
with the decreased hepatic dulne-s and increased size of the 
spleen, make the diagnosis clear. 

The prognosis is unfavoraljle. although ca-es of recovery 
have been reported (Frerichs and Schnitzlerj. 



244 



DISEASES OF THE ORGANS OF DIGESTION. 



The treatment is symptomatic. Cases of recovery have 
followed the use of aconite (Teissier) and benzoic acid and 
musk (Lebert). 

Weil's disease : A severe relapsing febrile infectious icterus, 
believed by some to be a distinct disease. Others consider 
the disease only a form of febrile icterus. In some cases the 
typhoid bacillus has been found, which led to the belief that 
the disease is a hepato-typhoid/' but this view seems to have 
been disproved by finding the typhoid bacillus in cases which 
did not show the symptoms of Weil's disease (Dupre). In 
some cases a bacillus has been found, the proteus fluorescens, 
which Jaeger believes to be the specific infectious agent (see 
also under Infections). 

FATTY LIVER. 

Definition : The liver in the normal condition contains more 
or less fat. An abnormal deposit of fat in the liver is termed 
fatty infiltration, except when it is formed at the expense of 
the albumin of the organ, when it is known as fatty degenera- 
tion. Fatty infiltration and fatty degeneration may not al- 
ways be readily differentiated, and often are associated. 

Etiology: The amount of fat in the liver may be increased 
by eating fat and sugars, and by sedentary habits. Fat often 
accumulates in the liver in alcoholism and in many of the 
acute infections, very frequently in tuberculosis. Fatty de- 
generation takes place in acute yellow atrophy, phosphorus- 
poisoning, and has been produced experimentally in animals 
by the injection of the toxins of the bacillus pyocyaneus 
(Charrin), and by the injection of variola-poison (Koux and 
Yersin). There may be a localized fatty degeneration in 
cases of carcinoma. 

Fatty liver — symptomatology : Light cases may show no 
symptoms. Pronounced cases sliow some enlargement of the 
liver, wliich does not present the normal solidity upon palpa- 
tion. The surface of the liver is smooth and the border rounded. 
The increased weight of the liver may cause displacement 
downward. There is little or no bulging of the thorax. 



AMYLOID LIVER. 



245 



Marked cases may show anorexia, vomitings diarrhoea, and 
hemorrhoids. 

The diagnosis of fatty liver is rendered probable by the 
presence of a uniform enlargement of the liver, with a smooth 
surface and rounded border, and with lessened resistance to 
pressure; and the absence of ascites, enlargement of the spleen, 
and jaundice. The history and physical examination may dis- 
close the etiological factor. 

Fatty liver should be differeiitiatcd especially from amyloid 
liver and leuksemia. Fatty liver frequently exists in com- 
bination with cirrhosis of the liver. The liver is then more 
si)lid upon percussion and the surface roughened, and there are 
ascites and enlargement of the spleen. 

The prognosis depends largely upon the cause, and is greatly 
influenced by complications, especially fatty heart and fatty 
kidney. Except in the cases due to poisons or infections 
(acute yellow atrophy), life may not be cut short. 

Fatty liver — treatment calls for removal of the cause, where 
this is possible. The treatment is largely symptomatic. 
Murchison recommends the internal use of large cpiantities 
of common salt. 

AMYLOID LIVER. 

Amyloid liver is usually associated with a similar involve- 
ment of the spleen, kidneys, and intestines. Amyloid matter 
is believed to be an albuminoid substance, which upon disin- 
tegration yields leucin and tyrosin. 

Etiology : Amyloid liver has been observed at various ages, 
from two to seventy years, usually between twenty and thirty, 
more frequently in men than in women. The process is 
usually secondary to some chronic suppurative disease, espe- 
cially tuberculosis and syphilis, and may follow malaria, leuco- 
cytiitemia, pseudo-leukpemia, rickets, or gotit. 

Amyloid liver — symptomatology: As a rule the liver is en- 
larged and iirra upon pressure, and the surface is sniooth. The hile 
is diminished in quantity and poor in quality, with consecjuent 
intestinal disturbance and tympanites. There are always some 
ancemia and leucocytosis. There may be numerous symptoms 



246 -DISEASES OF THE ORGANS OF DIGESTION. 



from affection of the spleen, kidneys, and intestines, and from 
the primary disease. 

Diagnosis : Suspicion may be aroused by amyloid disease 
in other organs, especially the spleen, kidneys, or intestine. 
Characteristic of amyloid liver is the great enlargement of the 
liver, with firmness on pressure, rounded border, freedom from 
pain or tenderness upon pressure, except when pain is caused 
by perihepatitis or syphilis ; and the presence of a chronic 
suppurative disease, tuberculosis, or syphilis. 

The prognosis is unfavorable as a rule, but better where 
the liver alone is involved. 

Treatment should address the cause, and is otherwise symp- 
tomatic. 

NEOPLASMS OF THE LIVER. 

Carcinoma of the liver : According to Eichhorst, carcinoma 
occurs, in the order of decreasing frequency, in the uterus, 
stomach, breast, and liver. 

Occurrence : Carcinoma of the liver occurs most frequently 
at from forty to sixty years of age. The disease has been 
found in early life, even in the new-born child (Siebold). 
Carcinoma of the liver occurs more frequently in women, 
secondary to involvement of the uterus, ovaries, or breast. 
The disease is less frequent in hot than in cold countries. 
Usually carcinoma of the liver is secondary to carcinoma of 
the uterus or gastro-intestinal tract, especially the pylorus, 
caecum, sigmoid flexure, or rectum; sometimes of the spine or 
right innominate bone. Carcinoma of the liver often follows 
traumatism from external violence or the irritation of biliary 
calculi. 

The symptoms of carcinoma of the liver may be slight and 
indefinite, sometimes overshadowed by other disease. The 
onset is often insidious. Emaciation is marked, sometimes 
intense. Often there is cachexia. As a rule, the liver is en- 
larged, especially in young persons. The enlargement is 
sometimes sufficient to cause bulging of the thorax. The 
liver may feel harder than no7'mal. Sometimes nodules may 
be detected by palpation. Often there is pain radiating 



DISEASES OF THE PANCREAS. 



247 



toward the right shoulder, through the connection between the 
phrenic and the fourth and fifth cervical nerves ; and in the 
lumbar region. Among the early symjjtoms are anorexia, 
nausea, vomiting, and sometimes constipation. Dian*hoea may 
be present later. There may be jaundice, tymjjanites, and 
ascites. 

Diagnosis : Differentiation between primary and secondary 
carcinoma of the liver may be difficult or impossible. The 
course of primary carcinoma of the liver is usually rapid and 
the enlargement of the liver more pronounced. 

The differenticd diagnosis concerns hydatid cyst, sarcoma, 
abscess, and amyloid liver ; syphilis of the liver ; carcinoma 
of the pylorus, pancreas, mesentery, colon or kidney ; and 
downward displacement of the liver. 

The prognosis is unfavorable. 

Treatment is palliative. 

Adenoma of the liver resembles carcinoma in symptoma- 
tology, but the duration of life is longer. The ^wognosis is 
unfavorable. Surgery offers the only hope of cure. 

Sarcoma of the liver occurs rarely as a primary disease, more 
frequently secondary to sarcoma elsewhere, especially in the 
region of the portal vein. As in sarcoma in other parts of the 
body, young persons are most frequently affected. The symj^- 
toms are similar to those of carcinoma of the liver. 

Angiomata of the liver are small. In children they may 
attain some size. Usually they do not cause vserious disturb- 
ance, and surgical treatment is unnecessary. Troublesome 
cases may demand resection of the liver. 

Fibromata, lipomata, gliomata, and cysts occur occasionally 
in the liver. 

DISEASES OF THE PANCREAS. 

Hemorrhage into the pancreas may occur in acute pancrea- 
titis or necrotic inflammation of the pancreas. Extensive 
hemorrhage may destroy the pancreas and invade the retro- 
peritoneal tissue ; or through a break in the peritoneal cover- 



248 DISEASES OF THE ORGANS OF DIGESTION. 



ing of the pancreas the hemorrhage may find its way into the 
lesser peritoneum. 

The symptoms come on in the miclst of apparent health, with 
severe pain in the upper part of the abdomen, Avith nausea 
and obstinate vomiting. Soon the patient becomes anxious, 
restless, and depressed. There are epigastric tenderness and 
sometimes marked tympanites. The temperature may be 
normal or subnormal. There may be constipation. These 
symptoms continue and the patient soon falls into collapse. 

Treatment: Death is probably due to shock through the 
solar plexus (Zenker), and not to the loss of blood ; and there- 
fore it has been suggested that probably the best treatment 
would be to expose the pancreas and thereby relieve the 
pressure. 

Pancreatic cysts are often due to traumatism or inflamma- 
tion ; but both these factors may be absent. Cyst of the pan- 
creas has been observed in an infant six months old (Railton); 
but the great majority of cases occur between thirty and forty 
years of age. 

The symptoms come on gradually, sometimes suddenly, as 
after traumatism, with attacks of colicky pain, nausea, and 
vomiting, and often with progressive enlargement of the ab- 
domen. There may be glycosuria. Jaundice and dyspnoea 
may be caused by pressure. So-called pancreatic salivation, 
an increased secretion of saliva, is rare. Emaciation is some- 
times marked. Transitory disappearance of the cyst has 
been reported. 

Diagnosis : As a rule the cyst lies below the stomach and 
above the colon, and is aflPected little or not at all by respira- 
tion. The cystic fluid is alkaline in reaction ; specific gravity, 
1010-1020. Most important is the presence of ferments. 
The digestion of both fibrin and albumin is characteristic of 
the pancreatic secretion. 

Treatment is surgical. Korte reports 101 cases in which 
the cyst was opened and drained, with a direct loss of only 
4 cases. In 14 extirpations there were 12 recoveries. 

Tumors of the pancreas : Carcinoma is the most frequent 
new growth. Much more rare are sarcoma, adenoma, and 



DISEASES OF THE PANCREAS. 



249 



lymphoma. The most important syriiptoms are epigastric 
paio^ often paroxysmal in character; icterus, due to pressure; 
the presence of a tumor in the epigastrium, which may be 
difficult to detect ; emaciation and cachexia, nausea and vom- 
iting. Fatty diarrhoea and glycosuria are not common. 

Treatment is surgical. Six recoveries in ten operations have 
been noted by Korte. 

Pancreatic calculi, pancreatic lithiasis, is rare. The stones 
are white and usually numerous, as a rule composed of car- 
bonate of lime, sometimes with phosphate of lime. Severe 
colic, glycosuria, and fatty diarrhoea were observed by Licht- 
heim in a case in which the diagnosis was confirmed by 
autopsy. 



CHAPTER III. 



DISEASES OF THE ORGANS OF RESPIRATION. 

DISEASES OF THE NOSE. 

Diseases of the exterior of the nose belong rather to the 
domain of dermatology or surgery. Those most commonly 
met are boils (furuncles); warts (verruca); acne; hyper- 
trophy, which is sometimes wrongly termed lipoma, but resem- 
bles elephantiasis elsewhere ; sebaceous tumors ; nsevus ; 
rodent ulcer; lupus; rhinoscleroma ; epithelioma; and in- 
juries. 

Of more interest to us are the diseases of the interior of 
the nose. 

ACUTE CATARRH OF THE NOSE. 

Acute rhinitis : An acute inflammation of the nasal mucous 
membrane, sometimes due to mechanical or chemical irrita- 
tion, is usually caused by the action of bacteria or toxins. 
Iodine internally may cause iodism, manifested by coryza and 
the usual symptoms of a " cold." 

Attacks of acute nasal catarrh are frequently precipitated 
by changes of temperature, especially by the exposure of a 
portion of the body to cold and moisture. Bad ventilation is 
one of the most prominent causes. 

Chronic inflammation of the nasal mucous membrane may 
predispose to acute attacks of nasal catarrh. 

The symptoms of acute nasal catarrh, coryza, commonly 
known as a cold," are too well known to need description. 
Aside from the local symptoms, there are general symptoms, 
usually ascribed to toxaemia. 

The diagnosis of acute rhinitis is easy ; but sometimes we 
may not readily locate the cause. The attack comes on 

250 



ACUTE CATARRH OF THE NOSE. 



251 



Fig. 29. 




Vertical section of head, slightly diagrammatic. 1, superior turbinated bone ; 2, 
middle turbinated bone : 3. lower turbinated bone ; 4, floor of nasal cavity ; 5, 
vestibule; 6, section of hyoid bone; 7, ventricular band; 8, vocal cord; 9, 
section of thyroid cartilage ; 10, 23, and 24, section of cricoid cartilage ; 11, sec- 
tion of first tracheal ring ; 12, frontal sinus ; 13. sphenoidal cells : 14, pharyngeal 
opening of Eustachian tube ; 15, Rosenmiiller's groove ; 16, velum palati ; 17, 
tonsil ; 18, epiglottis ; 19, adipose tissue behind tongue ; 20, arytenoid cartilage; 
21, tubercle of epiglottis; 22, section of arytenoid muscle (Seiler). 



252 DISEASES OF THE ORGANS OF RESPIRATION. 



^\ith malaise and chilliness ; later there are some fever, loss 
of appetite, and pains in the joints. The swollen mucous 
membrane causes occlusion of the nasal passages. There may 
be frontal headache and affection of the eyes in severe cases. 
Soon there appears an acid discharge from the nose, usually 
with sneezing, sometimes with excoriation of the lip. With 
the beginning of the discharge the occlusion of the nose 
becomes less. Later the discharge changes to muco-purulent. 
The duration of the attack is about a week. 

The prognosis is almost always good, but depends upon the 
cause. 

Prophylaxis: As a rule ''^ colds" are contagious. Feeble 
individuals should not be exposed to the danger of infection. 
Many cases would be prevented by attention to hygiene, 
especially personal cleanliness and proper ventilation. Coryza 
due to the administration of iodine (iodism) may be relieved 
by the discontinuance of the drug, or, where this is undesirable, 
by the administration of morphine. 

Acute rhinitis — treatment : If possil^le, the cause should be 
discovered and removed. Defective hygiene must be cor- 
rected. The body should be kept clean. 

The number of remedies is legion ; space forbids even their 
enumeration. The nasal mucous membrane may be cleansed 
w^ith an alkaline or astringent douche or spray, or with a 
cotton-wrapped sound. Increased nasal secretion may call 
for atropine. The toxic symptoms may be relieved by one 
of the coal-tar products, or opium in some form, best as 
Dover's powder. Often very great relief is afforded by the 
hot hath. 

CHRONIC CATARRH OF THE NOSE. 

Chronic rhinitis : Chronic nasal catarrh may be caused by 
an acute catarrh of the nose becoming subacute and later 
chronic. Thus the causes of acute catarrh of the nose, when 
long continued, may produce a chronic catarrh of the nose. 
Common causes are bad ventilation, dust, tobacco, and snutf. 

The symptoms are less inteuse than in acute catarrh of the 
nose, and of longer duration. As in acute catarrh, the mucous 
membrane is swollen. 



NON-MALIGNANT NEW GROWTHS IN THE NOSE. 253 



Diagnosis calls for difFerentiation from acute catarrh, poly- 
pus, and syphilis. Inspection reveals the mucous membrane 
swollen, especially over the turbinated bones, and covered 
mo e or less by secretion. There may be ulcers or erosions of 
the mucous membrane. 

Prognosis : Sometimes chronic catarrh is quite obstinate to 
treatment, but persistence is usually rewarded by a cure. 

Prophylaxis demands good hygienic surroundings and the 
avoidance of dust and the use of tobacco and snuff, things 
wdiich play a prominent part in the causation of rhinitis. 

Chronic rhinitis — treatment : The mucous membrane should 
be carefully cleansed. At first it is usually best to use an 
alkaline wash, and later an astringent solution. 

Bad cases may require a change of climate. 

Syphilitic rhinitis : SypMlit'w catarrh of the nose is charac- 
terized by lesions involving the deeper structures as well as 
the mucous membrane. Frequently there are evidences of 
syphilis elsewhere. Doubtful cases justify the therapeutic test. 

NON-MALIGNANT NEW GROWTHS IN THE NOSE. 

Polypi (myxomata) are the form of tumor occurring most 
frequently in the nose. The appearance of these growths 



Fig. 30. 




Adenoid hypertrophy at vault of pharynx (Lefferts). 

has been likened to the pulp of a grape. At first they may 
cause sneezing and a thin, watery discharge. They cause more 



254 DISEASES OF THE ORGANS OF RESPIRATION. 



or less occlusion of the nose and diminish or destroy the sense 
of smell. Numerous and diverse reflex disturbances are 
attributed to them. The voice is deadened. Frequently there 
are bronchitis and laryngitis. 

The diagnosis is made by inspection, best after the applica- 
tion of cocaine. The treatment is surgical. 

Other non-malignant tumors whicli may be found in the nose 
are fibromata, papillomata, angiomata, chondromata, osteo- 
mata, rarely cystomata. It is doubtful whether pure adeno- 
mata occur in the nose. Adenoids of the naso-pharynx (Fig. 
30) may be mentioned. The treatment of all these tumors 
belongs to surgery. 

DISEASES OF THE LARYNX. 

ACUTE CATARRHAL LARYNGITIS. 

Acute inflammation of the laryngeal mucous membrane is 

usually due to infection^ which is favored by some disturbance 
in the nose, obstruction, chronic inflammation ; or pharynx, 
acute or chron c pharyngitis. Frequently mouth-breathing 
plays an important role in etiology. Other causes are the 
inhalation of impure air, dust, irritating fumes or vapors, 
excessive use of the voice, and certain exanthemata, especially 
measles and scarlet fever. 

Symptoms: The voice becomes hoarse, there is dysphonia, 
sometimes aphonia. Cough may be present. General symp- 
toms are absent or mild, unless there is at the same time in- 
volvement of other })arts of the respiratory tract. 

Diagnosis : Hoarseness, dysphonia, or aphonia should lead 
to a laryngoscopic examination, to find the cause of these 
symptom-. Such an examination would reveal a symmetrical 
inflammation of the mucous membrane of the larynx, bright 
red in color and swollen, the vocal cords pink ; and would 
exclude other affections of the larynx, especially syphilis, 
tuberculosis, paralysis, and tumors. 

Prognosis : As a rule, the disease lasts about a week ; from 
five to eight days (Bosworth). 

Prophylaxis calls for pure air, the proper treatment of dis- 



CHRONIC CATARRHAL LARYNGITIS. 



255 



eases of the nose and pharynx, and the avoidance of mouth- 
breathing. Singers and public speakers should avoid over- 
taxing the voice. 

Acute laryngitis — treatment: Kest of the voice should be 
enjoined. Any nasal or pharyngeal disease should receive 
proper attention. It is better to confine the patient to a room 
that is comfortably warm, the air of which is kept moist with 
steam. The larynx may be cleansed with an alkaline solution 
and then treated with an astringent solution, such as a 1 per 
cent, solution of the liquor ferri persulphatis, or a 0.5 per 
cent, solution of nitrate of silver. These solutions are intro- 
duced upon a cotton-wrapped sound or in the form of a spray. 
Relief may be secured by the use of the steam atomizer. The 
application of cold to the neck, in the form of cold compresses, 
the ice-bag, or Leiter's coil, may be of value. The bowels 
should be kept open. 

CHRONIC CATARRHAL LARYNGITIS. 

Chronic catarrhal laryngitis may be due to a continuance of 
the causes of acute catarrhal laryngitis. Many cases depend 
upon deflection of the nasal septum or hypertrophic rhinitis. 
The disease is frequently found in individuals who use the 
voice excessively, and among those who indulge in alcoholic 
beverages. 

Symptoms : The voice becomes husky and hoarse, especially 
upon exercise, singing, or speaking. There are numerous 
attempts at clearing the throat. As in acute catarrhal laryn- 
gitis, there may be cough. The absence of cough would indi- 
cate that the disease has not extended below the larynx. 
Rarely there is aphonia, which is usually temporary. 

Diagnosis : The altered character of the voice, huskiness and 
hoarseness, should lead to a laryngoscopic examination, which 
would reveal a chronic inflammation of the larynx. The 
raucous membrane of the larynx is red and swollen, the blood- 
vessels injected. The vocal cord-, instead of being glistening 
white, will appear grayish or pinkish, and will not approxi- 
mate as well as in health. 

The differential diagnosis is not always easy. Many cases 



256 DISEASES OF THE ORGANS OF BESPIRATTON. 



are due to tuberculosis and syphilis, and will be considered in 
connection with those diseases of which they form a part. 

Prognosis : Spontaneous recovery does not occur, as in 
acute catarrhal laryngitis. Under treatment, which slionld 
include attention to any accompanying disease in tlie nose or 
pharynx, the affection may disappear and the voice return to 
its normal strength and clearness. 

Prophylaxis is the same as for acnte catarrhal laryngitis. 

Chronic laryngitis — treatment : Diseases or malformations 
on the part of the pharynx or tonsils, which may have a 
causative relation to the laryngitis, should be removed. After 
cleansing the larynx with an alkaline wash, upon a cotton- 
wrapped sound or in the form of a spray, a 4 per cent, solu- 
tion of ichthyol, a 1 per cent, or 2 per cent, solution of nitrate 
of silver, or some other astringent may be used. The value 
of resting the voice should not be overlooked. Erosions or 
chronic thickening of the mncous membrane n^.ay call for the 
local application of Lugol's solution and glycerin, 1 : 3, after 
the use of cocaine, 4 per cent., or a mixture of equal parts 
of cocaine, 4 per cent., and antipyrin, 10 per cent., which 
gives a more lasting ansesthesia. These applications may be 
repeated twice a week for a month or so. Obstinate cases 
may require curetting and the application of lactic acid under 
cocaine anaesthesia. 

(EDEMA OF THE LARYNX. 

Etiology : The most frequent causes of oedema of the larynx 
are those which may cause dropsy elsewhere. Most important 
is disease of the kidney. Sometimes oedema of the larynx 
is caused by iodism, aneurism, or by a tumor pressing on the 
cervical veins. 

Symptoms : The onset is usually sudden. The most striking 
symptom is inspiratory dyspnoea, Avhich may become extreme 
in a few hours. Deglutition may be painful and difficult. 

Diagnosis : The symptoms point to stenosis of the larynx. 
Upon laryngoscopic examination the laryngeal mucons mem-, 
brane is found to be oedematous. 

The prognosis depends upon the cause. In the absence of 



LAB YXGEAL PERICHOyDRITIS. 



257 



treatment a case may terminate fatally in a few hours, from 
suffocation. 

Treatment : (Edema of the larynx due to kidney-disease 
or cirrhosis of the liver may be relieved by free catharsis, 
\yhich may be secured quickly by the administration of croton 
oilj gtt. j, or elaterium, gr. ss ; and by free diaphoresis, whk'h 
may be readily caused hy the hypodermatic use of pilo- 
carpine, gr. \, best given with alcohol internally to avoid de- 
pression. 

A weak heart may need stimulation, best with the fluid 
extract of digitalis or tincture of strophanthus subcutane- 
ously. The patient should be kept in a warm room, the air 
of which is kept moist with steam. 

Tumefaction of the larynx may be relieved by scariflcation, 
which should be repeated if necessary. Severe cases may de- 
mand intubation or tracheotomy. 

LARYNGEAL PERICHONDRITIS. 

Laryngeal perichondritis is frecjuently found in connection 
with carcinoma, tuberculosis, syphilis, typhoid fever, diph- 
theria, pneumonia, erysipelas, and traumatism. Most cases 
are ascribed to exposure to cold or abuse of the voice. 

Symptoms : After more or less malaise and cliilly sensa- 
tions, the attack comes on with headache, anorexia, sometimes 
with pain in the bones, and fever, lOO'^-lOl^ F. Respira- 
tion, the use of the voice, and deglutition may be interfered 
with. Larvngoscopic examination reveals affection of the 
laryngeal cartilage. 

Diagnosis : There are dyspnoea and the symptoms of acute 
inflammation. Larvngoscopic examination shows not only 
an acute inflammation of the larynx, but also an irregular 
swelling, usually upon one side. The cases due to tuberculo- 
sis run a chronic course ; those due to syphilis are marked by 
pain and respond to the therapeutic test. 

Laryugeal perichondritis should be d Or crenfi cited especially 
from croup and actite submucous laryngitis. Croup shows an 
exudate. In submucous laryngitis the swelling is generally 
symmetrical and involves both sides. 

17— P. M. 



258 DISEASES OF THE OEGANS OF RESPIRATIOK 



Prognosis : The chief danger is through stenosis of the 
larynx, wliich may demand intubation. Cases chie to tuber- 
culosis or carcinoma have a bad prognosis. In all cases the 
course of the disease is long and tedious. 

Laryngeal perichondritis — treatment : Cold may be applied 
to the neck and ice given internally. Sometimes relief is 
secured by scarification of the endolaryngeal tissues. Pain 
is relieved by the application of cocaine or the adminis- 
tration of morphine. The bowels should be kept open. 
Cases due to syphilis call for the use of the iodides. Bos- 
worth advises the use of iodide of potassium during the acute 
stage, even in the absence of a history of syphilis. Dyspnoea 
may call for intubation or tracheotomy, or better laryngotomy. 
Sequestra shoidd be removed, adhesions liberated, and strict- 
ures dilated. 

SYPHILIS OF THE LARYNX. 

Primary sypliilitic lesion of the larynx occurs so rarely as 
to be considered a medical curiosity. The secondary lesions 
of syphilis may appear in the larynx as an erythema or a 
mucous patch, in four months to two years, usually within a 
year after the primary lesion. 

More frequent in the larynx are the tertiary manifestations 
of syphilis: gummata, deep ulcerations, and cicatricial stenoses. 

Prognosis : Under treatment the disease may be arrested ; 
but destruction of tissue will be followed by cicatrization, 
which may lead to stenosis of the larynx. 

The medical treatment is that of syphilis in general. Steno- 
sis may demand dilatation, intubation, or tracheotomy. 

TUBERCULOSIS OF THE LARYNX. 

Laryngeal tuberculosis is usually secondary to pulmonary 
tuberculosis; but tuberculosis may be primary in the larynx. 
Here, as elsewhere, tuberculosis is due to infection by the 
tubercle bacillus. 

Symptomatology : The voice becomes altered, weak, some- 
times aphonic. The use of the voice requires great eflPort. 



CARCIXOMA OF THE LARYNX. 



259 



There may be an involuntary change from a low tone to a 
falsetto note^ which may be maintained for a short time 
(Moure). The emaciation caused by the pulmonary tubercu- 
losis, which usually precedes the affection of the larynx, is 
increased, and the expression of the patient becomes anxious. 
AVith extension of the disease, deglutition becomes difficult 
and painfuL Destruction of the epiglottis may permit food 
to enter the larynx. 

Diagnosis : A reaction to tuberculin or the presence of the 
tubercle bacillus in the sputum would be of little value in 
diagnosis, since in most cases there is tuberculosis of the 
lungs before involvement of the larynx. Cases of pulmonary 
tuberculosis may show alterations of the voice, due to non- 
tubercular affection of the larynx. Of most value in diag- 
nosis is the laryngoscopic examination. 

Tuberculosis of the larynx should be differentiated espe- 
cially from syphilis and carcinoma. 

The progncsis is grave. Eleven recoveries in fifteen cases 
have been reported by Heryng. The cases usually succumb 
to pulmonary tuberculosis. With improvement in the treat- 
ment of tuberculosis of the lung we may hope to save more 
cases of laryngeal tuberculosis. 

Treatment : Probably of most yalue is the application of 
lactic acid or nitrate of silver. Orthoform may be used 
locally for the relief of pain. Climatotherapy and the use of 
tuberculin are important. Further than this the treatment is 
largely symptomatic (see Treatment of Tuberculosis). Opera- 
tion may be justifiable, especially in the absence of pulmonary 
tuberculosis. Pain should be relieved by morphine and 
cocaine. 

CARCINOMA OF THE LAEYNX. 

Carcinoma rarely affects the larynx. Men are affected more 
often than women. The disease occurs most frequently after 
fifty. 

S3rtnptomatology : The voice shows early impairment. There 
is dyspnoea. Cough is caused by tlie mucous or sero mucous 
discharge. The breath is offensive (the odor has been de- 
scribed as musty), and there is more or less hemorrhage. As 



260 DISEASES OF THE OBGANS OF RESPIRATION. 



a rule there are pain, sometimes difficult deglutition. Cachexia 
comes on late or may be absent. 

Early diagnosis is difficult or impossible. Later the symp- 
toms, the peculiar laryngoscopic appearance, and the pro- 
gressive course of the disease may render the diagnosis more or 
less absolute. In doubtful cases a positive diagnosis may be 
made by a microscopic examination of a portion of the 
growth. 

Prognosis : The disease is almost absolutely fatal. Cases 
of apparent cure by operation have been reported (Billroth, 
Butlin). Bosworth gives the fatality of operation at over 90 
per cent. 

Treatment : Early and complete removal of the growth is 
important. It must be remembered that the process extends 
beyond the apparent infiltration of the lymphatics. A great 
obstacle to operation is offered by the difficulty experienced 
in making an early diagnosis. Otherwise the treatment is 
symptomatic. 

SARCOMA OF THE LARNYX. 

Sarcoma occurs in the larynx very rarely. The majority of 
the reported cases have occurred in men. The ages of the 
patients have ranged from nineteen to seventy-four years, 
most of the cases occurring between forty and sixty. 

Symptomatology : Tlie voice becomes hoarse, sometimes 
aphonic. There are dyspnoea, cough, sometimes dysphagia. 
There may be slight hemorrhage and some pain. Late in the 
course of the disease there may be some cachexia. 

Diagnosis : Suspicion of malignancy may be aroused by the 
symptoms and laryngoscopic examination. A positive diag- 
nosis may be made by microscopic examination. 

A point in the differential diagnosis from carcinoma is 
the involvement of the cervical glands late in carcinoma, 
which is usually absent in sarcoma. 

The prognosis is grave. Very few recoveries have been 
reported. 

Treatment : The only hope of cure lies in operation. All 
other treatment is palliative. 



BENIGN TUMORS OF THE LARYNX. 



261 



BENIGN TUMORS OF THE LARYNX. 

Benign tumors are found in the larynx much more fre- 
quently than malignant growths. Bosworth gives the order 
of frequency as follows : papillomata, fibromata, cystomata, 
myxomata, adenomata, lipomata, angiomata, enchondromata, 
and mixed tumors. It is doubtful whether pure adenomata 
occur in the larynx. 

The chief symptoms are interference with phonation and 
respiration. 

The diagnosis is made with the laryngoscope. Differential 
diagnosis may call for the use of the microscope. 

The prognosis is usually good. These tumors rarely offer 
serious interference to respiration. 

Treatment, where necessary, is surgical. 

Neuroses of the larnyx : The chief neuroses of the larynx 
are : paralysis, spasm of the glottis (laryngismus stridulus), 
muscular incodrdination, neuralgia, hyper^esthesia, parses- 
thesia, anaesthesia, and hysterical aphonia. 

DISEASES OF THE TRACHEA AND BRONCHI. 

The trachea and bronchi are rarely affected primarily. 
Diseases of the trachea and bronchi usually come from above, 
the larynx ; or from below, the bronchial tubes ; and in most 
instances the disease of the trachea or bronchi is overshad- 
owed by the primary affection. Malignant disease of the 
trachea and bronchi is usually secondary. 

Summary : The mucous membrane of the trachea may be 
inflamed to constitute an acute or chronic catarrhal tracheitis. 
Diphtheria, has been reported to occur primarily in the 
trachea ; but in the great majority of cases it is secondary to 
invasion of the larynx. The trachea or bronchi may show 
ulceration, acute or chronic, and stenosis. Tumors of various 
kinds may occur in the trachea or bronchi ; or these organs 
may suffer compression, due usually to diseases in the thyroid 
gland, the mediastinal glands, the vertebrae (tuberculosis), 
oesophagus, aorta (rarely due to large pericardial effusion). 



262 DISEASES OF THE OBGANS OF RESPIRATION. 



The diagnosis of diseases of the trachea and bronclii may be 
difficult. In such cases the use of the laryngoscope may give 
valual)le information, but the examination is much more diffi- 
cult than inspection of the larynx. 

BRONCHITIS. 

Etiology : Bronchitis is due to infection in the vast majority 
of cases, either directly through the invasion of the bronchial 
mucous membrane by micro-organisms ; or indirectly, through 
the elimination of toxins, as may be observed especially in 
typhoid fever and cerebro-spinal meningitis. Bronchitis may 
also be caused by the elimination of poisons other than the 
toxins referred to, especially iodine and alcoliol. Many of 
the exanthemata, particularly measles and smallpox, show 
bronchitis. Direct invasion of the bronchial mucous mem- 
brane usually is an extension of an inflammation from the 
upper respiratory passages, the mouth or nose, or may be 
caused by trauma. 

ACUTE BRONCHITIS. 

Definition: An acute inflammation of the bronchial mucous 
membrane. 

Etiology : Most cases are attributed to " catching cold." 
'^Catching cold" usually occurs in badly ventilated apart- 
ments, rather than in the open air. Sometimes the disease is 
due to mechanical or chemical causes, dust, or irritating fumes. 
An acute bronchitis is often found in connection with the in- 
fections, especially measles and the respiratory foi'm of influ- 
enza. The most prominent predisposing causes are tubercu- 
losis, syphilis, rheumatism, gout, diabetes, Bright's disease, 
cancer, and heart-disease. An acute bronchitis appears in 
some individuals following the use of even small quantities of 
iodide of potassium. Acute bronchitis occurs most frequently 
in the colder months, and especially at the extremes of life. 
The disease is very common among the users of alcoholic 
beverages, probably due to elimination through the bronchial 
mucous membrane. Acute bronchitis is often caused by too 
little exercise in the open air. 



ACUTE BRONCHITIS. 



263 



Acute bronchitis — symptomatology : Usually there are the 
general symptoms of an infection — chilly sensationS;, fever, in- 
(jreased pulse-rate, malaise, anorexia, headache, often a coated 
tongue, more or less constipation, and in severe cases there 
may be pain in the limbs. The last- mentioned symptom 
would seem to indicate a toxcemia. 

The early local symptoms are dryness and constriction in the 
region of the larger bronchial tubes, the bronchi and trachea, 
frequently with hoarseness and a dry cough, from involvement 
of the larynx and trachea. There may be dyspnoea. In a 
few days the exudation from the bronchial mucous membrane 
becomes more profuse. There is expectoration. Light cases 
may last but a week or two. 

In more severe cases there may be sleeplessness and prostra- 
tion. In the aged the temperature may be subnormal. As a 
rule the dyspnoea becomes greater the further the inflamma- 
tion extends toward the air-cells, amounting sometimes to 
orthopnoea. Children may have convulsions. 

The chief coniij/ir:itions are inflammation of the upper air- 
passages, laryngitis and tracheitis, and atelectasis and broncho- 
pneumonia. 

Diagnosis and physical signs : Percussion may be negative, 
or may reveal dulness in the presence of atelectasis. Expira- 
tion is prolonged. Subcrepitant rales may be found when the 
inflammation involves the smaller ramifications of the bron- 
chial tubes. These may be heard on both sides, especially at 
the base of the lungs. 

Differential diagnosis calls especially for the recognition of 
pneumonia or broncho-pneumonia. 

Of most importance as a rule is the recognition of the 
cause of the bronchitis, especially tuberculosis, syphilis, rheu- 
matism, gout, diabetes, Bright's disease, measles, and whoop- 
ing-cough. 

Prognosis : The mortality increases as we approach the ex- 
tremes of life, and also as the inflammation advances along 
the finer bronchial tubes toward the air-cells. IMore deaths 
occur in winter than in summer. Mild cases usually recover 
in a week or two A fatal result does not often occur among: 
robust adults and children. The prognosis assumes gravity 



264 DISEASES OF THE ORGANS OF RESPIRATION. 



with the cause, the condition of the patient, and the severity 
of the attack. 

Acute bronchitis — treatment : The patient should occupy a 
warm, well-ventilated room, exposed to the sun. The air of 
the room may be kept moist with steam, or the patient may 
obtain relief by the use of a deaiii atomizer, or by inhaling 
steam from a kettle or pitcher. The compound tincture of 
benzoin may l)e added to tlie water. Catharsis should be 
secured by a mercurial or saline laxative. Diaphoresis is some- 
times of value. There are a large number of expectorants. 
As a rule the best are apomorphine, ipecac, and squills. Cough 
and insomnia may be relieved by the use of codeine, morphine, 
or opium, best in the forui of Dover's powder, which may be 
given in a syrup. Hot applications may be made to the chest, 
or turpentine or a weak mustard plaster may be used. Rub- 
bing the chest with a liniment may secure some relief, at least 
of the mind of the patient. An emetic is sometimes useful in 
the case of infants wlio may not be able to expectorate. The 
aged may require alcohol, senega, and carbonate or chloride of 
ammonium. Lihalatioiis of oxygen are recommended, espe- 
cially at the extremes of life. During convalescence, tonics, 
fresh air, and exercise are of value. 

Where the bronchitis is secondary to syphilis, rheumatism, 
or diseases of the lungs, heart, kidneys, etc., the treatment 
must address the primary disease. 

Capillary bronchitis : The term has been applied to an acute 
bronchitis affecting the finer bronchial tubes. Such a division 
of bronchitis is an over-refinement. It is difficult to imagine 
a case in Avhich such an inflammation would not extend to the 
air-cells to constitute a broncho-pneumonia. 

CHRONIC BRONCHITIS. 

Definition : A chronic inflammation of the bronchial mucous 
membrane. 

Etiology : Chronic bronchitis may result from an acute 
bronchitis, especially when the attacks of acute inflammati()n 
are frequently repeated. Chronic bronchitis is also found in 



CHRONIC BRONCHITIS. 



265 



tuberculosis, emphysema, asthma, disease of the heart, espe- 
cially stenosis or insufficiency of the mitral valve ; rheumatism, 
gout, diabetes, alcoholism, or where almost any of the causes 
of acute bronchitis, such as the inhalation of dust, are long 
continued. To some of the causes of acute bronchitis toler- 
ance may be established before the production of chronic 
bronchitis. Chronic bronchitis is usually found in middle or 
advanced life. 

Clironic bronchitis — symptomatology : The onset is gradual. 
The symptoms iniprove in summer, to become aggravated in 
winter. As in acute bronchitis, there may be dyspnoea and 
discomfort under the sternum. There is more or less cough, 
which in bad cases may become violent. The cough may 
cause insomnia. Sputum may be almost absent, or present in 
varying amounts, sometimes constituting a bronchorrhoea. 
There may be fetor, usually due to sputum retained in dilated 
bronchi. Sometimes the bronchi are not dilated. 

The physical signs resemble those of acute bronchitis. The 
duration of the disease is indefinite, but longer than in acute 
bronchitis. 

The principal complications are atelectasis, broncho-pneu- 
monia, emphysema, bronchiectasis, and dilatation of the heart, 
usually of the right side of the heart. 

Diagnosis : The history and symptoms render valuable aid. 
Chronic bronchitis should be differentiated, especially from 
pneumonia and tuberculosis. Chronic bronchitis differs from 
pneumonia in being a bilateral affection without evidence of 
consolidation and with little or no fever. Tuberculosis usually 
shows a more marked decrease of weight and greater weak- 
ness, and, as a rule, the tubercle bacillus may be found in the 
sputum. In doubtful cases the differential diagnosis may call 
for a test-injection of tuberculin. 

Prognosis : Much depends upon the cause of the broncliitis, 
the severity of the disease, and the strength of the patient. 
Chronic bronchitis is most dangerous in the feeble and aged. 
The prognosis should be guarded in the presence of emphy- 
sema, bronchiectasis, or dilatation of the heart. 

Clironic 'bronchitis — treatment : The general or curative treat- 
ment of bronchitis must address the underlying cause, what- 



266 DISEASES OF THE ORGANS OF RESPIRATION. 



ever that may be. All other treatment is palliative or 
symptomatic. 

Bronchitis due to cardiac insufficiency may be relieved by 
purgation, diaphoresis, and the use of stimulants, digitalis, 
strophanthus, alcohol, and nitroglycerin. 

Bronchitis due to pressure from an aneurism or tumor may 
be relieved by opium. Iodide of potassium may be of 
value. 

Rheumatism or gout should be properly treated with the 
salicylates, Carlsbad salts, colchicum, etc. (see Rheumatism 
and Gout). Where bronchitis is due to the inhalation of dust, 
irritating vapors or fumes, a change of occupation may be 
necessary. Tuberculosis, pleurisy, disease of the liver, or any 
other disease upon which the bronchitis may depend should 
receive proper attention. 

For the dry catarrh, the " catarrhe sec " of Laennec, opium, 
best in the form of codeine, morphine, paregoric, or Dover's 
powder, often affords great relief, but should not be used 
when there is high fever or great prostration. Chronic 
bronchitis is a disease of long duration, and opium may 
not be indefinitely continued. Heroin, or heroin hydro- 
chloride, in doses of 0.005-0.015 gm., diminishes the desire 
to cough, deepens and prolongs respiration, and relieves pain. 
Chlorate of potassium is a good expectorant. Various 
other sedatives, narcotics, and expectorants are recom- 
mended. i\[uch relief may be obtained from the inhalation 
of steam. 

Where the secretion is excessive and the cough unavailing, 
stimulating expectorants may be useful, such as senega, which 
may be given in teaspoonful doses of the simple syrup of 
senega, or gtt. xxx of the compound syrup of squills ; car- 
bonate and chloride of ammonium, balsam of copaiba, and the 
various preparations of turpentine; syrup, picis liq., 3ij-iv 
t. i. d. ; myrtol, turpentine, terebene, and terpene hydrate, 
TTLv t. i. d. Cubebs may be given in cough-lozenges. Apo- 
morphine is an excellent expectorant, but should not be given 
when there is a weak heart. Iodide of potassium may be 
given, gr. v-xxx ter die. Often very great comfort is secured 
from the use of the steam atomizer, in which various sub- 



FIBEIXO US BR ORCHITIS. 



267 



stances may be used.^ Sometimes a change of climate is 
advisable. Cases of dry bronchitis are usually benefited most 
by a warm, moist climate, such as may be secured in the 
Bermudas, Xassau, Florida, Southern Calilbrnia, the Azores, 
or Madeira. 



FIBHINOUS BRONCHITIS i Plastic Bronchitis!. 

Definition : An inflammation, acute or chronic, of the 
bronchial mucous membrane, cliaracterized by the formation 
of a fibrinous exudate in the bronchial tubes. The disease 
has been found in the new-born child on autopsy (Hayn). 
Fibrinous bronchitis, is most frequent between ten and forty 
years. The condition is rare in the aged. 

The etiology of the disease is obscure. Escherich (1883) 
failed to find the bacillus of diphtheria in the exudate. Three 
varieties of micrococci were isolated by Picchini (1889). 
Many cases have been observed to follow traumatism or 
chemical irritation. Exposure to cold and moisture is fre- 
quently given as a cause. Among the predisposing or under- 
lying causes the following have been observed : tuberculosis, 
syphilis, alcoliolism, rickets, pregnancy, and typhoid fever. 

Fibrinous bronchitis — symptoms : There are present the 
symptoms of an acute or chronic bronchitis. At times cough 
and dyspnoea become intense, to be relieved by the expulsion 
of a fibrinous bronchial cast. These casts are branched like 
a tree, corresponding to the ramifications or branches of the 
bronchial tubes from which they are expelled and of which 
they f )rm a cast. The casts vary in size, usually an inch to 
an inch and a half in length, rarely reaching a length of four 
inches or over. Haemoptysis is a common symptom. 

^ Mason, in the Am'ii-ican Smtem of Practical Medicine, gives the following 
list of substances that may be used with the atomizer, with the quantity of 
each to be added to one ounce of water : 



Tincturte iodii. "n\,ij-x ; 
Acidi carbolici, gr. ij ; 
Creosoti. iTLiij : 
Acidi tannici. err. ij-x : 
Alumini exsiccati. gr. iij-xv ; Tincturre hyoscyarai, rr^xxx-lx; 

Liquoris ferri snbsulphatis, gtt. v-xx ; Tincturoe stramonii, TTLxxx-xl : 
Tincturse opii, TT^v-xxx ; i Tincturse belladoimnae, TTLxxx-xl 



Tincturse opii camphoratse, ; 
Morphinfe sulphatis, gr. ss-j ; 
Solut. cocainse hydrochlorici (4 per 
cent. ), TTLxxx-lx 



268 DISEASES OF THE ORGANS OF RESPIRATION. 



Diagnosis : Finding the peculiar casts makes the diagnosis. 
A localized subcrepitant rale may be suggestive (Flint). 
Blood-casts may appear in cases of haemoptysis, and should 
not be mistaken for the casts characteristic of fibrinous bron- 
chitis. Acute pneumonia and diphtheria also may show casts. 

Prognosis : Fibrinous bronchitis is most dangerous at the 
extremes of life. Death is most frequently caused by com- 
plications, or the underlying diseases which predispose to 
fibrinous bronchitis. Extension of the exudate into the 
trachea or inability to expel casts may cause death by suffoca- 
tion. Aside from other diseases of the lungs, especially tuber- 
culosis, the prognosis is usually good. 

Treatment : Of most value are inhalations of steam and the 
use of expectorants, particularly after the cast becomes loose. 
Probably the best expectorant in these cases is apomorphine. 
Iodide of potassium seems to be of little or no value. 

BRONCHIECTASIS (Dilatation of the Bronchial Tubes). 

Etiology : Most of the cases are probably due to weakening 
of the walls of the bronchial tubes, caused by chronic bron- 
chitis. Many cases are caused by whooping-cough, measles, 
tuberculosis, asthma, and pleurisy. Sometimes cases may be 
caused by obstruction of the air-passages by foreign bodies, 
enlarged glands, tumors, aneurisms. Rarely the condition is 
congenital. 

The symptoms in cases of slight or moderate dilatation may 
not be characteristic. Marked dilatation of the bronchial 
tubes may be followed at times, especially in the morning, by 
expectoration of large quantities of muco-purulent sputum, 
often foetid in character. 

On physical examination percussion may reveal the presence 
of cavities. The signs of bronchitis are usually present. 

Diagnosis : In slight or moderate cases of bronchiectasis 
diagnosis may be impossible during life. In doubtful cases 
the diagnosis may call for an exploratory puncture. Bron- 
chiectasis should be differentiated especially from tuberculosis, 
actinomycosis of the lung, pulmonary gangrene or abscess, and 
empyema. The diagnosis of tuberculosis or actinomycosis of 



ASTHMA. 



269 



the lung may be established by an examination of the sputum 
for the tubercle bacillus and ray fungus respectively. Gan- 
grene and abscess of the lung show more pronounced general 
symptoms than are present in bronchiectasis. Bronchiectasis, 
barring complications, shows little or no fever and only slight 
general symptoms, except in cases that are far advanced. An 
empyema that discharges through the lung may closely simu- 
late bronchiectasis, but usually shows fever, and sometimes 
pneumococci may be found in tlie sputum. 

The prognosis is best in childhood ; worst in the weak and 
aged, especially in the presence of consolidation or collapse 
(atelectasis) of the lung-tissue. 

Bronchiectasis — treatment : Some cases improve under the 
use of iodide of potassium, probably only when syphilis plays 
a role in etiology. Some relief may be aflPorded by inhalation 
or administration of turpentine, creosote, tar, menthol, euca- 
lyptus, myrtol. Some cases have been successfully treated 
surgically by incision and drainage ; but surgery does not 
offer as much hope as in the treatment of abscess of the lung. 
In most cases of bronchiectasis that have been operated upon 
the operation has only hastened a fatal termination. 

ASTHMA. 

Definition : A peculiar dyspnoea, characterized by difficult 
and prolonged expiration, hypersemia of the bronchial mucous 
membrane, more or less acute emphysema of the lung, and 
sibilant rales. The sputum often shows Charcot-Leyden 
crystals and Curschmann spirals. 

Etiology : Depending upon the cause, asthma is divided into 
(1) primary asthma, sometimes called bronchial asthma or 
pulmonary asthma ; and (2) secondary asthma, which is sub- 
divided into cardiac asthma, renal asthma, etc. With the 
advance of our knowledge of the etiology of asthma the num- 
ber of cases of primary asthma are diminishing, while the 
secondary asthmas are increasing. 

Asthma is supposed by some observers to be due to con- 
tracture of the bronchial muscles, through some affection of the 
nervous system, the cause of which is known in secondary 



270 DISEASES OF THE ORGANS OF RESPIRATION, 



asthma and unknown in primary asthma. Asthma is more 
frequent in men than in women. 

Cases wliich have seemed to depend upon swollen tracheal 
or bronchial glands have been explained by the supposition 
that such enlargements cause irritation of the vagus nerve 
through pressure. 

An important role has been ascribed to a special susceptibil- 
ity of the nervous system that in some individuals causes an 
asthmatic attack to follow stimuli that in other individuals 
would be without such effect. In many cases heredity seems 
to play a part. Asthma may alternate with other neuroses, 
such as epilepsy, hemicrania, angina pectoris. 

Nasal polypi and other affections which interfere with the 
respiratory function of the nose are a frequent cause of asthma. 
Such cases have been ascribed to reflex irritation. 

In some instances the attacks are observed to occur only 
during the menstrual period. 

Cullen gives the account of an apothecary's wife who had 
an attack \vhen ipecac was handled in the shop. Trousseau 
had an attack in the presence of a bouquet of violets. Itzig- 
son records the case of a merchant who would have an attack 
when fresh coffee was handled in his presence. Mackenzie 
reports the case of a lady who had an attack upon seeing a 
rose, even though it were artificial {psychic asthma). 

Most cases of asthma occur at night, often regularly at the 
same hour. In some cases the attacks will not appear if a 
light is left burning. 

Many cases of asthma seem to bear a relation to gout, and 
in some cases a seeming relation with chronic skin diseases 
(herpes, psoriasis, and eczema) has been reported. 

Symptomatology : Asthmatic attacks occur suddenly at irregu- 
lar, sometimes regular, intervals, usually in the night-time, 
with inteiwals of apparent perfect health. The attack is char- 
acterized by severe dyspnoea, calling for the use of all the 
accessory muscles of respiration. The difficulty is with 
expiration, which is prolonged. The hunger for air causes 
the patient to assume a posture that \\\\\ give freedom and 
power to the accessory muscles of respiration. There is 
cyanosis. The attack may continue for a few minutes to a few 



ASTHMA. 



271 



hours, when the symptoms gradually, sometimes suddenly, 
disappear. 

Laryngoscopic examination shows the mucous membrane of 
the trachea and visible bronchi reddened. 

Physical signs : Percussion reveals an increased lung-area,, 
the border of the lungs extending further downward, with a 
lower position of the liver. The heart-dulness is diminished. 
Upon auscultation, sibilant rales are heard, replaced toward 
the end of the attack by moist rales. A vesicular respiratory 
murmur is heard over parts of the lungs. 

Fever is absent, or, if present, would 
denote complication. In children espe- 
cially a rise of temperature is often due 
to catarrh. Expectoration usually occurs 
only toward the end of the attack. The 
frothy, grayish-white sputum contains the 
Charcot-Leyden crystals and Curschma nn 
spirals (Fig. 31). Spirals have been 
found also in pneumonia, fibrinous bron- 
chitis, acute and chronic catarrhal capil- 
lary bronchitis, diseases which affect the 
smaller bronchi and bronchioles. The 
sputum contains eosinophile and gramdar 
cells (Mastzellen), and crystalline and 
amor])hous phosphate of lime. Durins; c. • i i + i • 

1 1 -t . & Spirals and crystals m 

the attack large numbers of eosmophiie sputum of asthma, 
cells have been observed in the blood by 
many observers. Other observers have failed to confirm 
this finding. 

The more common complications are bronchitis, gout, dis- 
eases of the skin (herpes, psoriasis, eczema), epilepsy, neu- 
ralgia, pulmonary emphysema, and bronchiectasis. Tuber- 
culosis may occur in an asthmatic patient, but is not common. 

Diagnosis : Asthma is characterized by paroxysmal expira- 
tory dyspnoea. The sputum usually contains Curschmann 
spirals, Charcot-Leyden crystals, and eosinophile cells. Dur- 
ing the attack there are an acute emphysema and sibilant, later 
moist, rales. IN'ot all dyspnoeas are asthmas. 

Prognosis : Where the cause can be discovered and removed 



Fig. 31. 




272 DISEASES OF THE ORGANS OF RESPIRATION. 



the case may be cured. Frequently treatment is followed 
only by a cessation of symptoms^ which may last even for 
years, and finally return. Cures are more frequent in early 
life. Asthma rarely causes death. 

Asthma — treatment : Treatment of the attack : Any dis- 
coverable cause should be removed. Attacks may be cut 
short by the use of opium, morphine, or chloral ; but these 
remedies may not be used continuously. Belladonna, atropine, 
cannabis Indica, and strychnine may be used. Chloroform, 
ether, methylene bichloride, and ethyl iodide may be inhaled, 
but have only a transitory effect. The leaves of stramonium 
and belladonna have long been in use, smoked either with or 
without tobacco. A good combination is the following, given 
by Trousseau as the composition of the cigarettes Espic : 

^ Fol. elect, herb, belladonnse, 0.36 ; 

Fol. elect, herb, hyoscyami, 0.18 ; 

Fol. elect, herb, stramonii, 0.18 ; 

Fol. elect, phellandrii aquat., 0.06 ; 

Extract opii, 0.008 ; 

Aquse laurocerasi, q. s. 

This is made into a cigarette and one or two such cigarettes 
may ])e smoked during an attack. 

In some cases those who are not accustomed to the use of 
tobacco may gain much benefit from its use. Arsenic and 
nitre are also used, blotting-paper being soaked in a solution 
of these substances, then dried, and smoked or burned and the 
fumes inhaled. The inhalation of ammonia is often of value. 
Electricity is sometimes used, the induced or faradic current. 

Cases due to nasal irritation may be relieved by the local 
application of cocaine. 

Treatment during the intervals: Often a local cause in the 
upper respiratory organs or in the genital organs may be dis- 
closed and treated or removed, when the symptoms will dis- 
appear. Sometimes several points of irritation may be found. 
The iodides may be given internally, 1.5-3.0 per day, pre- 
scribed in peppermint- water and taken largely diluted in 
milk. The remedy must be given for a long time. Fowler's 
solution of arsenic is often of value. Numerous remedies 



CEOUPOUS PNEUMONIA. 



273 



and contrivances have been recommended. In each case the 
physician should seek and treat or remove the cause. This 
sometimes may call for a change of residence. Good hygienic 
surroundings and exercise, especially open-air respiratory 
gymnastics and hydrotherapy, are often of very great value. 

DISEASES OF THE LUNGS. 

PNEUMONIA. 

Definition : An infection of the lung by various micro- 
organisms, the invasion of which may be favored by exposure 
to inclement weather, trauma, etc. 

Varieties : (1) croupous pneumonia, lobar pneumonia, fibrin- 
ous pneumonia, sometimes referred to as genuine pneumonia; 
(2) catarrhal pneumonia, lobular pneumonia, broncho-pneu- 
monia. To these may be added (3) influenza pneumonia, due 
to the influenza bacillus ; (4) tul)ercular pneumonia, due to 
tlie tubercle bacillus, and really a tuberculosis ; (5) true typhoid 
pneumonia, due to invasion of the lung by the typhoid bacil- 
lus. The term typhoid pneumonia has been abused so much 
that many suggest that the term should be dropped altogether. 
(6) Septic pneumonia, set aside by some observers as a special 
variety, due to the pus-producing micro-organisms. Such 
cases, when possible, may be classified according to the par- 
ticular variety of micro-organism present, as streptococcus 
pneumonia, staphylococcus pneumonia, etc. 

CROUPOUS PNEUMONIA (Lobar Pneumonia; Fibrinous Pneu- 
monia; Genuine Pneumonia). 

Definition : An infection of the lung, affecting an entire 
lobe, characterized by a fibrinous exudate with rusty-colored 
sputum, high fever, and termination by crisis in five to nine 
days. 

Etiology : The infectious agent is the micrococcus pneu- 
moiiJcr ci'ouposce (Sternberg) or the bacillus of Friedlander. 
Tliese micro-organisms have been found upon the respiratory 
mucous membrane, especially in the mouth and throat, in 
IS— p. 



274 DISEASES OF THE ORGANS OF RESPIRATION. 



health, and it would seem that exposure to cold and moisture 
and trauma may play an important role in etiology. In some 
cases other micro-organisms have been found, such as the in- 
fluenza bacillus, streptococcus pyogenes, staj^hylococcus pyo- 
genes aureus, and the typhoid bacillus ; but in such cases the 
disease does not pursue the typical course of croupous pneu- 
monia. 

Croupous pneumonia — symptomatology : Some cases show 
prodromata for two or three days : malaise, more or less in- 
flammation of the respiratory mucous membrane, especially 
of the nose and pharynx, and indigestion. 

Usually there are no prodromoia. The disease is announced 
suddenly with a cliill, followed by fever, the temperature 
reaching 104° or 105° F. As a rule, sooner or later there is 
jmin in the side, usually in the region of the nipple, caused 
by involvement of the pleura. Dysjmoea is prominent, due 
to pain or to the congestion of the lung. 

All sorts of rales may be heard. 
Fig. 32. coarse and fine, moist and dry. 

This constitutes the stage of en- 
gorgement, which in a day or two 
gives way to consolidation, often 
with relief of the pain and dyspnoea. 

TJie tempei-cdure continues high, 
with rapid jmlse and respiration, 
anorexia, thirst, headache, constipa- 
tion. The urine is reduced in 
quantity and highly colored. The 
sputum becomes rusty -colored. 
Usually the cough is painful. 

Temperature-curve of croupous rm " ,i i 

pneumonia. Ihcrc are restlessness and more or 

less delirium. 

As a rule, between the fifth and ninth day resolution is an- 
nounced by a sudden fall of temperature, crisis, Avith profuse 
perspiration (Fig. 32). Occasionally the temperature falls by 
lysis, reaching the normal in a few days instead of a few 
hours. The pulse falls from 110 or 120, sometimes 150 in 
children, to 50 beats per minute. 

Croupous pneumonia — physical examination : Inspection re- 




CR 0 UPO US PNE UMONIA. 



21b 



veals lessened expansion of the affected side. Palpation may 
detect increased vocal fremitus and sometimes a pleuritic fric- 
tion-sound. Percussion usually sho^Ys increased resonance 
over the affected lobe during the period of congestion, which 
during the period of hepatization (consolidation) gives way to 
dulness. After resolution resonance reappears. Aiiscultation 
discloses both fine crepitant and coarse rdles during the period 
of congestion. The former disappear during consolidation of 
the exudate. The breathing then becomes bronchial. There is 
bronchophony, sometimes segophony, over the affected lobe. 
With resolution, bronchial breathing and bronchophony give 
way to the crepitus redux, moist rales which are usually coarser 
than the fine moist rales heard during the period of conges- 
tion. In central pneumon ia, in which the affection of the lobe 
does not extend to near the perijihery, auscultation may reveal 
only bronchophony. 

Especially in severe cases, the heart is called upon to do 
increased work and the cardiac dulness is found to extend 
further to the right. Usually there is accentuation of tlie 
second pulmonary valve sound. There is often enlargement 
of the spleen and liver. 

Croupous pneumonia — examination of the blood : There is a 
marked leucocytosis, 20,000-e32,000 (Ewing). In a very viru- 
lent case as high as 100,000 has been recorded (Kidd). As a 
rule, a low number, below 14,000 (Ewing), lends gravity to 
the prognosis. A very high number is found in severe cases. 
The number of leucocytes gradually diminishes just before 
crisis and returns to the normal after resolution. An increase 
in the leucocytosis would indicate a further invasion of the 
pulmonary tissue. 

Complications : Bronchitis and pleurisy occur frequently 
with croupous pneumonia. Sometimes there is empyema. 
Pericarditis is found most frequently in pneumonia of the 
left lung. Occasionally there are endocarditis, meningitis, 
nephritis; more rarely peripheral neuritis, uretliritis, paro- 
titis, and orchitis. 

Diagnosis : Usually the symptoms and physical examination 
render the diagnosis easy. The disease comes on suddenly, 
with increased respiration, sometimes localized pain in the 



276 DISEASES OF THE ORGANS OF RESPIRATION. 



region of the nipple, with cough, later rusty sputum and 
physical evidences of consolidation of the lung upon the 
affected side. 

Pneumonia of the apex of the lung may resemble tubercu- 
losis, but does not show the tubercle bacillus in the sputum 
nor respond to the test with tuberculin. In such cases, as 
well as in cases of central pneumonia, in which the physical 
signs may be absent or misleading, an examination of the 
blood will show leucocytosis. Acute pulmonary oedema may 
show dyspnoea, cyanosis, rales, and sometimes sputum some- 
what resembling that of pneumonia. Acute oedema usually 
depends upon disease of the heart, and is not accompanied by 
high fever. Pleurisy usually comes on more gradually and 
does not show rusty sputum. Doubtful cases may call for 
aspiration. Pluerisy and croupous pneumonia may co-exist. 

Prognosis : ^Much depends upon the condition of the heart. 
The prognosis should be extremely guarded when the heart is 
enfeebled by age, alcoholism, or disease. The occurrence of 
complications adds gravity to the case. Pneumonia occurring 
in pregnancy, especially in the later months, frequently causes 
miscarriage and a fatal termination. In any case marked and 
persistent increased frequency of the pulse and respiration, 
the expectoration of prune-juice " sputum, persistent tracheal 
rales, the typhoid state with low delirium, stertor, muscular 
tremor, and coma, are ominons signs. 

Croupous pneumonia — treatment : In the way of specific 
medication most promising are the results that have been ob- 
tained by the injection of blood-serum from recent convales- 
cents. Frequently crisis occurs immediately or soon after 
such injections. The effectiveness of serum-therapy is as- 
cribed to an antipneumotoxin, which normally accumulates in 
the body of the patient to cause the crisis on the seventh to 
the ninth day of the disease. We should not forget, in the 
application of serum-therapy, that all cases of pneumonia are 
not due to the same micro-organism. 

In general the treatment is symptomatic. The sick-room 
should be well ventilated. Some temperature belongs to the 
disease and is salutary ; temperature above 103° F. calls for 
hydrotherapy, best sponging with cold water, and the use of 



CA TAREHAL PXE UMOSIA . 



277 



ice upon the chest. Severe pain may be relieved by mor- 
phine ; cough that is distressing, by Dover's powder. Ner- 
vous symptoms — headache, sleeplessness, delirium — may call 
for sponging with cold water or the application of the ice-bag 
or cold compresses to the head, or the administration of 
Dover's powder or trional at Vjedtime. 

Most im])ortant is the snijjjort of the heart. A flag'ging 
heart calls for the use of alcohol and strychnine. Xitro- 
glycerin or musk may be used to bridge over a threatened 

'r.Lij i-r. Digitalis or -trophanthus may be indicated by weak- 
nc-- the heart. Sume Ijrilliant results have been reported 
fr<jm the use of large do-es of digitalis or digitalin ; ljut others 
have failed to secure such results by the use of these remedies 
in pneumonia. 

Good results have been reported (Lepine) from the intra- 
pulmonary injection of bichloride of mercurv, 20-26 c.c. of 
a 1 : 4000* solution. 

CATAEEHAL PNEUMONIA Broncho-pneumonia : Lobular 
Pneumonia . 

Definition : An inflammation of the lung, affecting the 
lobules, finer brnnchi. and air-cells, usually f 'llovving bron- 
chitis, and in the great maji'rity of case- due to infection. 

Etiology: The micro-or-;nii-iii- most frequently found in 
catarrhal pneumonia are tin • inici Mcoccus pneunmniie crouposte 
(Sternberg), Friedlander's bacillus. strcpt< >(■< ,ccu^ j.yn-rnes, 
staphvlocnccus pyogenes aureus, diphtheria liarillu-. inhuenza 
Viar'illu-. tubercle bacillus, and the typhoid V)acillus. Mixed 
infection is very common. 

Pneumonia due to the diphtheria bacillus, influenza ba- 
cillus, tubercle l)acillus. and typhnid b^icillus is treated of 
under Diphtheria. Influenza. Tubereu]<:>-is. and Typhoid 
Fever, respectively. 

Frequently catarrhal pneumMnia is due to the extension of 
a bronchitis. Capillary l)roncliitis. or bronchiolitis, rarely if 
ever exists except in the presence of liueumonia. 

Since manv of the micro-i:.rgani-m~ fMund in pneumonia 
may be present in the respiratory tract, especially in the nose 



278 DISEASES OF THE ORGANS OF RESPIRATION. 



and throat, and probably also in the kings, in health, an im- 
portant role in causation is ascribed to exposure to inclement 
weather, cold, and moisture, the inhalation of dust and anaes- 
thetics, and trauma, which are believed to favor infection. 

The so-called aspiration-pneumonia, which occurs most fre- 
quently after anaesthesia, is due to an invasion of the lung by 
micro-organisms, which gain access to the lung in abundance 
at the time of anaesthesia, through the increased secretion and 
diminished expectoration. In such cases infection may be 
favored by the irritation of the lung caused by the anaes- 
thetic. 

Symptomatology : The symptoms bear a general resemblance 
to those of croupous pneumonia, but show wide variations, as 
might be anticipated from the variety of agents that may 
enter into the etiology of catarrhal pneumonia. The symp- 
toms of Gcu-bonic-acid poisoning and toxaemia assume impor- 
tance. 

The more important symptoms are fever, usually 102° to 
103° F. in the evening, sometimes 104° to 105° F.; rapid 
pulse, 150 or higher, and respiration 20 to 60 or more; dysp- 
noea, and cough. The pulse-respiration ratio is altered from 
the normal 2 : 9 to 1 : 3-2 : 3. 

Physical signs : Percussion may elicit some dulness, usually 
near the spine and low down. Auscultation reveals 7^dles of 
various kinds. Bronchial breathing and bronchophony are 
the exception. Resolution may take place, but usually appears 
later than in croupous pneumonia. 

The duration of the disease is longer in catarrhal pneu- 
monia than in croupous pneumonia. As a rule the temperature 
fails by li/sis. Often convalescence is protracted. Pericarditis, 
endocarditis, and meningitis occur only rarely. 

Catarrhal pneumonia — diagnosis : The disease shows a prefer- 
ence for the extremes of life. The existence of some etiolog- 
ical flictor, such as bronchitis, is often of value in diagnosis. 
Important symptoms are the elevation of temperature, in- 
crease of pulse and respiration, with disproportion of the 
pulse-respiration ratio, and the presence of rales. 

Physical examination may show infiltration of parts of a 
number of lobes, involving usually both lungs. Croupous 



CATARRHAL PNEUMONIA. 



279 



pneumonia, on the other hand, shows consolidation of an en- 
tire lobe, and is usually unilateral. 

In catarrhal pneumonia the sputum is muco-parulent and 
may contain blood, but is not of the rusty character found in 
croupous pneumonia. In some cases the microscopic exami- 
nation of the sputum will reveal the true nature of the dis- 
ease. 

Prognosis : The mortality is much higher than in croupous 
pneumonia. The outlook is grave in children after measles, 
whooping-cough, and diphtheria. High temperature, ^vith 
dyspnoea, irregular respiration, especially Cheyne-Stokes 
respiration, delirium, convulsions, and somnolence are omi- 
nous, especially late in the course of the disease. 

Catarrhal pneumonia — treatment : The treatment is sympto- 
matic. High fever, above 103° F., calls for hydrotherapy, 
best cold sponging, or a warm or cool bath. In the presence 
of a strong heart, especially in children, phenacetin or lacto- 
phenin, best given with whiskey or wine to avoid depression, 
may give considerable comfort. Such measures also address 
most pleasantly the nervous distress so often present. Pleu- 
ritic pain may be relieved by hot or cold applications, a mus- 
tard plaster, or the administration of opiam. The patient 
should drink plenty of pure water, plain or carbonated, to 
which lemon-juice or cream of tartar may be added. Emetics 
are sometimes useful for the removal of the secretion from the 
trachea. Of more value are the stimulating expectorants, 
senega, ammonia, camphor, and benzoic acid. 

A weak heart should be supported with cold sponging, 
digitalis, alcohol, strophanthus, caffeine, carbonate of ammo- 
nium. Nitroglycerin is of value in cases of arterio-scelerosis. 

The patient should be kept upon a fever-diet : milk, soup, 
eggs ; later oysters, chicken, and steak. 

A change of climate may be necessary in chronic cases. In 
all cases the patient should receive an abundance of pure 
fresh air (see Treatment of Bronchitis). 

Influenza-pneumonia (see Influenza) : The prognosis is worse 
than in the other forms of catarrhal pneumonia or in croupous 
pneumonia. 



280 DISEASES OF THE ORGANS OF RESPIRATION. 



Tubercular pneumonia (see Tuberculosis). 

Typhoid pneumonia (see Typhoid Feverj. A true typhoid 
pneumonia may be caused by the typhoid bacillus, and occurs 
especially in the course of typhoid fever, the infection of the 
lung probably occurring through the blood. In some cases 
the infection of the lung by the typhoid bacillus has seemed 
to occur tlirough the respiratory tract (Richiardierej. The 
fever, nervous symptoms, and couise of the disease resemble 
those of typhoid fever. Sometimes the term " typhoid pneu- 
monia^^ is applied incorrectly to a combination of typhoid 
fever and croupous or catarrhal pneumonia. 

EMPHYSEMA (Pulmonary Emphysema). 

Definition : Vesicular emphysema shows dilatation of the 
pulmonary alveoli with distention of the alveolar walls, which 
sometimes atrophy and disappear. In interstitial empJiysema 
there is inflation of the interstitial lymph-spaces of the lung 
with air that escapes from the alveoli through rupture. 

Etiology : The most prominent factor in causation is in- 
creased intrapulmonary pressure, due to expiratory effort. 
Emphysema is found most frequently in chronic bronchitis, 
especially in dry bronchitis and in certain occupations, among 
musicians who play on wind-instruments, glass-blowers, and 
those who do heavy lifting, in which the glottis is closed and 
the accessory expiratory muscles are brought into action. 
Congenital weakness of the pulmonary tissue seems to play a 
role in some cases. 

Symptomatology : Vesicular emphysema comes on gradually 
and pursues a chronic course. With the disappearance of the 
alveolar walls the aerating surface in the lung is diminished. 
There is dyspnoea, which is expiratory in character, at first 
observed only on exercise, later becoming more constant. 
The dyspnoea is aggravated l)y bronchitis. Usually there is 
cough. Because of the lessening of the pulmonary vascular 
area the heart must do more work. The rir/ht ventricle becomes 
hypertrophied, and. later underr/oes dilatation. The tricuspid 
valve becomes relatively insufficient. There are cyanosis and 



EMPHYSEMA. 



281 



dropsy, which may become general to constitute a true ana- 
sarca. The chest comes to occupy the position of inspiration, 
— becomes " harrel-slia'pedy The chest appears as if the indi- 
vidual were holding his breath at full inspiration. 

Inspiration is short and expiration prolonged and forced. 
The heart is pushed downward. The apex-beat may be in 
the sixth or seventh intercostal space. Epigastric pulsation 
is common. 

Physical signs : Percussion reveals drum-like tympanitic 
resonance; dimlnutio)), sometimes obliteration^ of the cardiac 
didness, due to the heart being covered by the lung. The 
pulmonary resonance is increased downward, and the liver 
may be pushed downward so that it can be readily pal- 
pated. 

Auscultation : Expiration is prolonged. In the presence of 
bronchitis, rales may be heard. Usually there is accentuation 
of the second pulmonary valve sound. With insufficiency of 
the tricuspid valve a systolic murmur is heard. 

The liver and spleen may be enlarged, especially late in the 
disease. 

Prognosis : In pronounced cases the prognosis is grave. 
Those who are able to take proper care of their health, espe- 
cially with regard to the selection of climate and the treatment 
or prevention of bronchitis, may live for years in comparative 
comfort. Where this is not possible the duration of life is 
shortened. In all cases the disease runs a chronic course. 
Life often is terminated by some intercurrent malady. Other- 
wise death comes through failure of the heart. 

Emphysema — treatment is symptomatic, and should be ad- 
dressed especially to the prevention or cure of bronchitis and 
the support of the heart. The patient should reside in a 
warm climate during the winter. Where this is not possible 
the individual should remain in the house in winter and 
during inclement weather. The remedies of most value in 
the treatment of the bronchitis are iodide of potassium, citrate 
of potassium, and pilocarpine. Strychnine is an excellent 
tonic. A failing heart demands rest and the judicious use of 
digitalis and strophanthus. OEdema may be relieved by 
calomel or diuretin. 



282 DISEASES OF THE ORGANS OF RESPIRATION. 



ATELECTASIS. 

Definition : Collapse or incomplete distention of a greater or 
less number of pulmonary alveoli. 

Etiology : Complete atelectasis is found normally in the lung 
of the foetus. In the new-born it is evidence that the child 
has not breathed. Acquired atelectasis may be due to 
plugging of a bronchus or compression of the lung. 

Symptomatology : Partial atelectasis shows increase of respi- 
ration and absence of fever, except when caused by associated 
processes. The respiration is superficial. The pulmonary 
area may be decreased and the cardiac area increased. The 
lung retracts from over the heart. 

Fercussion may reveal dulness or flatness over the affected 
portion of the lung. 

During life, atelectasis may be overshadowed by the symp- 
toms of the disease or condition which causes it. 

Treatment should address the cause, in the hope of preven- 
tion of complete atelectasis, which is incompatible with life. 

(EDEMA OF THE LUNG (Pulmonary (Edema). 

Definition : K collection of fluid in the interstitial tissue of 
the alveoli and smaller bronchioles. The fluid comes from 

the blood, through the vessel- walls, 
and may be clear or tinged with blood. 

Etiology : Passive congestion of the 
lung, due to a weak heart, is probably 
the most common cause. 

CEdema occurring in nephritis is 
due to changes in the vessel-walls or 
in the heart, weakness. QEdema may 
occur in the neighborhood of in- 
flammatory processes in the lung. 
Symptomatology : The onset may 
^w!'•i'/^^^^"'^^''' coal-dust be sudden or 2:radual. There are 

(Whittaker). S , . , /. 

dyspnosa, cyanosis, and increased jre- 
quency of respiration. Rales occur, at first with resonance, 
later with dulness or flatness over the more dependent portions 
of the lung. 



Fig. 33. 




(Edema piilmonum. Desqua- 
mated epithelial cells con- 



GANGRENE OF THE LUNG. 



283 



The sputum contains oedematous cells, known as cells of 
pulmonary oedema or the cells of heart-failure (Fig. 33). The 
sputum may contain urea in cases occurring in nephritis. 

The prognosis is always grave, hut depends upon the cause, 
especially upon the reaction of the heart to stimulation. 

Pulmonary oedema — treatment : Most cases are due to a weak 
heart, which should be strengthened by rest and the judicious 
use of cardiac stimulants and exercise. Grave cases may call 
for the analeptics, probably best, camphor and oil, 1 : 8, hypo- 
dermatically. Often considerable comfort is secured by the 
use of morphine. 

ABSCESS OF THE LUNG. 

Abscess of the lung may be single or multiple. 

Etiology : Among the causes of abscess of the lung are : 
tuberculosis, pneumonia, empyema, mediastinitis, oesophageal 
carcinoma, abscess of the liver, subdiaphragmatic abscess, em- 
bolism, and the presence of a foreign body in the lung. 

The diagnosis is difficult in the absence of expectoration of 
pus. Sometimes pus may be detected by aspiration. In the 
difPerentiation from a bronchiectatic cavity, when pus is ex- 
pectorated, the finding of portions of the lung or elastic tissue 
would speak for abscess. 

Treatment : If possible, the abscess should be treated sur- 
gically, opened and drained. In other cases the treatment 
must be expectant, symptomatic. As far as possible the cause 
should be addressed. 

GANGRENE OF THE LUNG. 

Primary gangrene of the lung, due to trauma, is rare. Gan- 
grene of the lung is most frequently caused by pneumonia, 
infarction, embolism, abscess, echinococcus, actinomycosis, 
neoplasms ; rarely by tuberculosis. The disease shows a pref- 
erence for males, poverty, and the age of twenty to fifty years. 

Symptomatology: The odor of the hreath is very offensive. 
Expectoration is usually abundant, and the sputum is foul- 
smelling, and upon standing separates into three layers : the 



284 DISEASES OF THE ORGANS OF RESPIRATION. 



upper muco-purulent, the middle thin and watery, and the 
lower purulent. Microscopical examination of the sputum 
reveals pieces of lung-tissue, especially elastic fibres, numer- 
ous bacteria, mould-fungi, and both fat-crystals and free fat. 
If the gangrene involve a considerable area, it may be recog- 
nized by the presence of dulness and bronchial respiration ; or, 
in the presence of a cavity, by tympanitic resonance, especially 
the crached-pot sound, and amphoric respiration. 

The prognosis depends largely upon the cause and the 
strength of the patient, but is always grave. Death is 
usually caused by exhaustion, sometimes by hemorrhage, 
rarely by abscess of some other organ, especially of the brain. 

Treatment : Inhalations of creosote lessen the offensive 
odor of the breath. Rarely surgery may benefit a case by in- 
cision and drainage. As a rule the treatment is purely symp- 
tomatic. 

PNEUMONOKONIOSIS. 

Definition : Disease due to the inhalation of dust. 

Varieties : Anthracosis or anthraco-pneumonokoniosis, coal- 
miners' phthisis, coal-miners' lung, due to the inhalation of 
coal dust, Siderosis, knife grinders' phthisis, refers especially 
to disease caused by the inhalation of particles of metal (steel 
and iron). Chalicosis is due to the inhalation of mineral dust. 
Millers^ phthisis is due to the inhalation of particles of wheat, 
especially of the hull of the grain. 

The symptoms are those of bronchitis, emphysema, intersti- 
tial pneumonia, or tuberculosis. 

The diagnosis rests upon the symptoms and occupation of 
the patient, and the character of the sputum, which contains 
particles of the dust inhaled. Frequently the irritation caused 
by the dust opens the way for invasion by micro-organisms. 
Many of the patients succumb to tuberculosis. 

Prognosis : Mild cases recover upon a change of occupation. 
In advanced cases the prognosis is bad. The invasion by 
micro-organisms, especially by the tubercle bacillus, adds 
gravity to the prognosis. 

Treatment : Something may be done in the way of prophy- 



PLEURISY. 



285 



laxi? by the use of inhalers, or of apparatus to remove the 
dust, e.-pecially in factories. 

The treatment of a case calls for a change of occupation. 
Further treatment is that of bronchitis. 

Syphilis of the lung (see Syphilis). 

Echinococcus of the lung (see Echinococcus). 

Actinomycosis of the lung (see Actinomycosis). 

DISEASES OF THE PLEURA. 
PLEURISY. 

Definition : An inflammation (infection), acute or chronic, 
of the membrane lining the pleural cavity. 

Etiology : Tuberculosis is the most frequent cause. Some 
cases are due to pneumonia, infarctions, rheumatism, syphilis, 
and infection with the typhoid bacillus. Typhoid infection 
of the pleura may occur either with or without intestinal 
lesions. Charrin and Roger (1891) found infection of the 
pleura with the typhoid bacilkis, \vithout infection of the 
intestine, in a postmortem upon a case in which there were 
the symptoms of typhoid fever, except those symptoms due 
to lesion of the intestine. Pleurisy may be caused by trauma 
or by Bright's disease. The streptococcus pyogenes is found 
most frequently in purulent pleurisy (see Empyema). Ex- 
posure to cold has come to occupy a subordinate place in 
etiology. 

Pleurisy — symptomatology : The acute attack comes on sud- 
denly with chill followed hij fever, 102° to 103° F., and in- 
creased pulsp-rrife. As a rule the most prominent early 
symptom is pain, usually in the side, which is aggravated by 
pressure, cough, or deep inspiration. At first the patient 
lies on the well side, to avoid pain, and later on the afPected 
side, to secure greater freedom of respiration. Effusion prob- 
ably begins soon after the onset of the disease, but usually 
may not be readily detected until the second to the fifth day. 
With the separation of the pleural surfaces by the effusion the 



286 DISEASES OF THE ORGANS OF RESPIRATION. 



pain disappea7'S. Usually the pulse and respiration are in- 
creased in frequency. As a rule the temperature continues 
high. Dyspnoea may be troublesome. 

Sometimes the onset of pleurisy is insidious. The patient 
complains of cough and shortness of breath brought on or 
increased by exercise. There may be pain in the side. The 
general health is impaired, the appetite is poor, and there 
is weakness, frequently pallor. Such cases occur most fre- 
quently at the extremes of life, usually secondary to other 
diseases, especially tuberculosis and chronic diseases of the 
heart and kidneys. 

In some cases there is no effusion, constituting the so-called 
dry pleurisy. Effusion, when present, may last two to 
five days in rheumatic cases (Netter); usually four to six 
weeks in acute cases with small .or moderate effusion ; and a 
number of years in chronic cases, before absorption takes 
place. 

Pleurisy — physical signs : At first the most important sign 
is the pleural friction-rub, heard both upon inspiration and 
expiration. Later there is the evidence of effusion, appearing 
first as didness over the most dependent portion of the })leural 
cavity. The friction-sound may still be heard above the area 
of dulness. With increased effusion the dulness becomes 
more pronounced ; there is absolute flatness. The respiratory 
movement of the affected side is diminished. Vocal fremitus 
is absent over the effusion and increased over the compressed 
lung. Large effusion causes distention of the affected side, 
displacement of organs, and bulging of the intercostal spaces. 
In marked cases auscultation may detect no sounds upon the 
affected side. Usually there are bronchial breathing and 
bro7ichophony, occasionally ^egophony. After absorption there 
is a return of the friction-sound, which is found over a larger 
area than at first. There are numerous crackling rales. 

The early diagnosis of pleurisy or the detection of mild 
cases depends largely upon the recognition of the friction- 
sound. Later, dulness and flatness are characteristic. Atten- 
tion often is first directed to the chest by the pain in the side. 
The symptoms may indicate the character of the exudate, 
which can be determined positively only by puncture. The 



E3IPYEMA. 



287 



examination of the exudate, microscopically and by inocula- 
tion and culture, may reveal the micro-organisms present in a 
given case. 

The prognosis depends largely upon the cause. So-called 
rheumatic pleurisy almost invariably pursues a short and 
flivorable course. Many cases of pleurisy seem to recover 
from the attack, and succumb later to tuberculosis. But even 
tubercular pleurisy may recover. Chronic pleurisy may cause 
permanent deformity of the chest. 

Pleurisy — treatment : The patient should remain in bed. 
Pain may be relieved by hot applications and poultices, and 
by strapping the side to prevent the movements of respira- 
tion. Severe pain calls for opium, best in the form of Dover's 
powder in broken doses ; or morphine hypodermatically. 
The bowels must be kept open. Fever is relieved best by 
cold sponging. Pleurisy due to tuberculosis, rheumatism, or 
syphilis should be treated with remedies addressed to these 
diseases — tuberculin, the salicylates, and iodides, respectively. 

An exudation that threatens life or is very slowly absorbed 
must be removed by aspiration or incision. Symptoms de- 
manding aspiration are asphyxia, weakness of the heart, rising 
of the fluid to or above the third interspace with the patient 
in the erect position, and delayed absorption. 

The puncture is best made in the fourth interspace on tlie 
left side, or the fifth interspace on the right side. ISTot all the 
fluid should be removed. 

EMPYEMA (Purulent or Suppurative Pleurisy). 

Etiology : The most frequent causes are the streptococcus 
pyogenes and the micrococcus pneumoniae crouposse. The 
tubercle bacillus opens the way for invasion of the pleura by 
other micro-organisms. The staphylococcus is usually found 
associated with the tubercle bacillus or the micrococcus pneu- 
raonise crouposse. The bacillus of Friedlander, the typhoid 
bacillus, and saprophytic micro-organisms are sometimes 
present. 

Infection of the pleura may come from the Jung, from pneu- 
monia, tuberculosis, abscess, gangrene, infarction, bronchiec- 



288 DISEASES OF THE ORGANS OF RESPIRATION. 



tasis, and cancer; from the chest-wall, from inflammations of 
the skin, lymphatic glands, or breast, especially cancer of the 
breast and peripleuritis ; from the mediastinum, from medias- 
tinal abscess, pericarditis, and cancer of the oesophagus ; from 
the abdomen, from peritonitis, and hepatic, subdiaphragmatic, 
and perityphlitic abscess ; and from certain infectious diseases, 
especially septicaemia (puerperal fever), erysipelas, influenza, 
scarlet fever, and diphtheria. Infection may occur through 
trauma (wounds). 

Symptomatology : Aside from the symptoms of pleurisy, in 
empyema there is evidence of the presence of pus in the pleural 
cavity. The onset of empyema may be sudden or insidious, 
and the course of the disease may be acute or chronica Usually 
sooner or later the temperature shows the curve character- 
istic of septicmmia. At the same time there are emaciation 
and loss of strength. The dyspnoea becomes greater than may 
be accounted for by the amount of fluid present in the pleural 
cavity. 

The symptoms vary somewhat with the cause. In empyema 
due to the streptococcus pyogenes the streptococcus (hectic) 
temperature-curve is usually present from the beginning. To 
this class belong, as a rule, the fulminant cases. CEdema of 
the chest-wall is frequent. Often there is enlargement of the 
axillary glands. Exceptionally metastatic abscesses occur, 
most frequently in the brain. 

Empyema due to the micrococcus pneumonice crouposce is 
usually, if not always, secondary to pneumonia, which may 
pass unrecognized. Frequently the course resembles that of 
pneumonia, with sudden onset, pain in the side, cough, and 
marked improvement in seven to nine days. Cases occurring 
after the crisis of pneumonia show a less characteristic course. 
CEdema of the chest-wall is rare. Spontaneous evacuation, 
oftenest through the lungs, less frequently through the inter- 
costal spaces, occurs in at least one-fourth of the cases. 

Encapsulation of the exudate occurs more frequently than 
in other varieties of empyema. The pus is dense and viscid, 
usually of a grayish-yellow color. This form of empyema 
terminates, as a rule, in recovery, which may account jfor the 
usually favorable course of empyema in children. 



EYDEOTHORAX. 



289 



Cases of empyema in which the tubercle bacillus is present 
are usually insidious in onset and pursue a chronic course. 

Fcetid or putrid empyema is caused by the presence of sapro- 
phytic micro-organisms. Frequently gangrene of the lung is 
the source of the infection. The cases usually present marked 
symptoms of sepsis. Often the expectoration is offensive^ 
even in the absence of discharge of the empyema. 

Cases of empyema due to the typhoid bacillus usually termi- 
nate favorably. As a rule^ the fever resembles that of typhoid 
fever. 

In many cases there is mixed infection. 

Diagnosis : The symptoms of pleurisy in combination with 
the evidence of septicaemia may lead to the suspicion of em- 
pyema. CEdema of the chest-wall occurring in pleurisy 
would indicate empyema. A positive diagnosis may be made 
by the withdrawal of pus, through aspiration or incision. 

Prognosis is good, provided early evacuation of the pus is 
obtained. Many cases undergo resolution without operation. 
Empyema is, however, a serious disease. Much depends upon 
the cause. 

Treatment : The pus may be absorbed, especially in chil- 
dren. As long as the general condition of the patient remains 
good, in the absence of marked evidence of septicaemia, the 
treatment may be expectant. 

Impairment of the health of the individual, especially 
changes in the pidse and respiration, calls for surgical inter- 
ference, incision, and drainage. Sometimes it is necessary 
to resect part of a rib to secure thorough drainage of the 
empyema. 

HYDEOTHOEAX. 

Definition : An oedematous transudation of fluid into the 
pleural cavity. 

Etiology : The causes are those which may produce cedema 
elsewhere : obstruction to the circulation, due to disease of 
the heart or of the lung (emphysema) ; hydraemia, due to 
kidney disease or cachexia. 

Symptomatology : There is dyspnoea, which may be aggra- 
19— p. M. 



290 DISEASES OF THE ORGANS OF RESPIRATION. 



vated by the conditions that produce the hydrothorax. Hy- 
drothorax does not cause pain or fever. 

Physical exanihiation reveals fluid in the pleural cavity , the 
character of which may be determined by aspiration. Hydro- 
thorax is ahiiost always bilateral. 

Dia^gnosis : The occurrence of bilateral transudation of fluid 
into the pleural cavity, in the presence of general oedema, is 
characteristic. Doubtful cases may be cleared up by aspira- 
tion. 

The prognosis depends upon the cause. 

Treatment should address the cause. In bad cases the 
fluid may be withdrawn by aspiration. In the presence of 
general dropsy, relief may be obtained by increasing the 
action of the heart, kidneys, and bowels ; or fluid may be 
withdrawn from the legs by the introduction of silver canulse 
into the subcutaneous tissue. 

PNEUMOTHORAX. 

Definition : Air in tlie pleural cavity. A combination of 
pneumothorax and hydrothorax constitutes pneumo-hydro- 
thorax. The presence of air and pus in the thorax is known 
as pneumo-pyo-thoi^ax. 

Etiology : Air may gain access to the pleural cavity through 
perforation. Cases may rarely be due to the presence of 
anaerobic gas-forming micro-organisms. Such organisms were 
found by Levy in a case of pneumothorax following pleurisy. 
But perforation is the more common cause. 

The perforation may be caused by trauma, as by a broken 
rib or rupture of the lung. Aside from trauma, the majority 
of cases are due to tuberculosis. Other causes are empyema, 
emphysema, pneumonia, gangrene of the lung, abscess of the 
lung or liver, carcinoma, and the emptying of a bronchiectatic 
cavity into the pleural cavity. 

Pneumotliorax — symptomatology : Usually the onset is sud- 
den, with pain, dyspnaa, and cyanosis. There may be cough. 
Prostratio n is marked. The j)ulse and. respiration are increased, 
the temperature subnormal. The patient may pass into col- 
lapse and die within a few hours or days ; or death may occur 



P^^E UMOTHORAX. 



291 



later from exhaustion. In other cases the symptoms improve 
and recovery follows with absorption of tlie air or gas. 

Physical examination shows enlargement of th.e affected side, 
with displacement of the organs, — heart, liver, and spleen, — as 
in })]enrisy. Vocal fremitus is diminished or absent over the 
affected area and increased over the collapsed lung. The 
percussion-note may be tympanitic, but is usually only loud 
with a low pitch. At any rate, the percussion-note over the 
affected area differs from that over the normal lung. Auscul- 
tation over the affected area reveals diminution of the respira- 
tory murmur. The sounds of respiration and the voice are 
distiuctly amphoric (metallic tinkle, which may also originate 
in the stomach). 

The presence of fluid or pus (pneumo-hydro-thorax, pneumo- 
pyo -thorax) may give rise to succussion. This should not be 
mistaken for succussion occurring in the stomach. Succussion 
may also occur in a large cavity in the lung. Soon the 
symptoms of fluid in the pleural cavity appear (see Pleurisy). 
The fluid changes its level with changes in the position of the 
body Qiore readily than when the hydrothorax is not accom- 
panied by the presence of air or gas. Usually the air or gas 
is soon absorbed after the appearance of fluid. 

Diagnosis : The sudden onset, dyspnoea, and the physical 
signs, especially the increased resonance, with feeble or 
amphoric respiration over the affected area, and the displace- 
ment of organs, especially of the heart and diaphragm (liver 
and spleen), are characteristic. The respiratory sounds may 
be entirely absent. Light cases are sometimes difficult to 
diagnosticate. 

Differential diagnosis has to do chiefly with emphysema, 
pulmonary cavities, hernia of the diaphragm, and pyo-pneumo- 
thorax subphrenicus. 

Prognosis : In the absence of infection the prognosis is good. 
Tubercular cases have a worse outlook. The occurrence of 
pus (pneumo-pyo-thorax) adds gravity to the prognosis. The 
prognosis is unfavorable in double pneumothorax. 

Pneumothorax — treatment : Pain should be relieved with 
hot applications, poultices, or opium, preferably in the form 
of morphine hypodermatically. Prostration and collapse 



292 BISEASES OF THE ORGANS OF RESPIRATION. 



should be met with the analeptics, alcohol, sodium benzoate, of 
caffeine, camphor, ether, digitalis, strychnine. Asphyxia may 
necessitate puncture with a hypodermatic needle or fine trocar, 
best made in the fourth to sixth interspace in front. 

Later, effusion may call for the intervention of surgery, 
aspiration, or incision and drainage. 

Echinococcus of the pleura (see Echinococcus). 

Malignant diseases of the pleura : Sarcoma rarely invades 
the pleura. 

Carcinoma, of the pleura is almost always secondary to 
carcinoma elsewhere. Primary carcinoma of the pleura has 
been reported in a few cases. 



CHAPTER lY. 



DISEASES OF THE ORGANS OF CmCULATION. 
DISEASES OF THE PERICARDIUM. 

PERICARDITIS. 

Definition : An acute or chronic inflammation of the peri- 
cardium. 

Etiology : Primary pericarditis may be due to trauma or 
causes a})parently not connected with other disease^ such as 
'^taking cold." 

More important, because much more frequent, are the cases 
of secondary pericarditis, which may be caused by the infec- 
tions or by extension of inflammation from contiguous organs, 
due to bacterial invasion or the action of toxins. Pericarditis 
is most frequently found in rheumatism, especially in acute 
articular rheumatism, chorea, tuberculosis, pleurisy, endocar- 
ditis and myocarditis, pneumonia, influenza, scarlatina, septi- 
caemia, variola, scorbutus, nephritis, gout, cholera, dysentery, 
erysipelas, diphtheria, cerebro-spinal meningitis, haemophilia, 
hemorrhagic diathesis, purpura, morbus maculosus, leukaemia, 
diabetes, cirrhosis of the liver, carcinoma, sarcoma, and 
syphilis ; typhus, typhoid fever, intermittent fever, relapsing 
fever, gonorrhoea, phlebitis, and osteomalacia. Aneurism is 
a rare cause. 

Symptomatology : The symptoms of pericarditis may be 
slight, overshadowed by associated disease, or entirely absent; 
again, they are pronounced. 

Sometimes the onset is sudden, with chill and rigor, a rise 
of temperature, malaise, anorexia, headache, and dizziness. 
There may be palpitation of the heart. In other cases the 
onset is insidious and these symptoms are not present. Some- 

293 



294 DISPJASES OF THE ORGANS OF CIRCULATION. 



times, especially in the aged, the temperature may be sub- 
normal. 

Frequently pericarditis first manifests itself by pain, which 
sometimes extends to the left shoulder and down the arm. 
There may be tenderness over the region of the heart and in 
the epigastrium. Sometimes the pain is increased by inspira- 
tion. Later, upon the appearance of effusion, the pain disap- 
pears or at least is diminished. The effusion interferes with 
the action of the heart. The pulse becomes weak and irregu- 
lar. Exertion or excitement may be followed by syncope. 
Frequently there is dyspnoea, Avhich may amount to orthopnoea, 
with cyanosis. Interference with the heart's action may lead 
to oedema, especially of the extremities, in some cases assuming 
the proportions of an anasarca. 

There may be distention of the cervical veins, with venous 
pulsation, dysphagia, and cough, sometimes aphonia, from 
pressure on the recurrent laryngeal nerve. 

Usually the patient lies upon the back, in a semirecumbent 
posture. The urine is high colored, and may contain albumin 
and blood, rarely casts. 

Pericarditis — physical signs : Inspection may reveal distention 
of the ribs, especially in children, and the presence of consider- 
able effusion. There may be more or less restriction of the 
respiratory movements. Sometimes a large effusion produces 
only tvidening and bulging of the intercostcd spaces, because 
of the inelasticity of the ribs. The apex-beat may be dis- 
placed to the left and upward. With absorption of the 
effusion all these signs disappear. 

Palpcdion may or may not detect tenderness over the heart 
or in the epigastrium. A friction-fr emitus may be felt. There 
is dislocation of the apex-beat, which may change with the j 
position of the body. Effusion, causing great distention, may 
l)e recognized by palpation. After absorption of the effusion 
the friction-fremitus may again become perceptible, and the 
apex-beat resumes its normal position. The friction-sound 
may disappear from effusion, adhesion, or resolution. 

Percussion shows enlargement of the heart-didness, when 
there is any c(msiderable amount of effusion. Dulness in the 
fifth intercostal space to the rigid of the sternum occurs early 



PERICARDITIS. 



295 



in pericardial effusion. In extreme cases the dulness may 
extend from the second rib, sometimes as high as the clavicle, 
down to the ensiform appendix, and from nipple to nipple. 

AusG'ultation is of most value in early diagnosis. Peri- 
caixlial friction-soimds, varying in character, occur synchronous 
with the heart-sound, sometin]es with respiration. The fric- 
tion-sounds are heard best during full inspiration with the 
body inclined forward, and are increased by pressure over the 
heart. The friction-sounds become less distinct, and finally 
disappear with the occurrence of effusion. The heart-sounds 
become muffled. Upon absorption of the effusion a friction- 
sound may again be heard, and the heart-sounds again become 
normal. The friction-sounds finally entirely disappear with 
absorption of the fibrin or adhesion of the pericardial sur- 
faces. 

Diagnosis : The symptoms may I e suggestive, but a diag- 
nosis can be made only upon physical examination. The 
pericardial friction-sound and the evidence of effusion, espe- 
cially dulness in the fifth intercostal space on the right of the 
sternum, the precordial dulness later assuming the shape of 
the pericadial sac, with the base of the triangle above, are 
characteristic. Aspiration may be necessary to detect effu- 
sion, and at the same time will reveal the character of the 
effusion. Sometimes aspiration may not detect fiuid in the 
pericardium even when present. 

Dfferentiation concerns especially endocarditis, pleurisy, 
hypertrophy of the heart, mediastinal tumors, and irritation 
or inflammation of the stomach. 

The prognosis varies with the cause, extent, and character 
of the inflammation and the general condition of the patient, 
especially the strength of the heart-muscle. The mortality is 
high at the extremes of life. The outlook is bad in tubercu- 
lar or purulent pericarditis. In all cases the prognosis should 
be guarded. Usually the cases due to rheumatism are lighter 
than those due to Bright's disease, pyaemia, or scurvy. 

Pericarditis — treatment : The first requisite is absolute rest 
in bed. Cold applications — an ice-bag or Leiter's coil — may 
be used early. Sometimes these are not tolerated, when they 
may be substituted by hot applications. It is better to keep 



296 DISEASES OF THE ORGANS OF CIRCULATION. 



the patient on a fever-diet ; milk and eggs form the best food. 
Opium, best in the form of Dover's powder, or morphine, 
may be given to relieve pain and quiet the heart's action. 
Violent action of the heart is best relieved by rest and the 
application of cold. Temperature that is excessive may be 
controlled by sponging with cold water. 

In the treatment of pericarditis due to rheumatism the sali- 
cylates are advised. DaCosta believes them useless, and that 
they may do harm by depressing the heart. 

Weak and irregular action of the heart may be met with 
digitalis. 

Large effusions may demand paracentesis, best in the fifth 
interspace about two inches to the left of the median line. 
Potassium salts, especially the iodide, acetate, and citrate, 
best in combination with digitalis, have been recommended to 
promote absorption of the effusion. In the presence of fever 
and irregular pulse quinine may be administered, gr. iij-v 
every four hours. 

Purulent cases should be treated surgically, by incision and 
drainage. 

PERICARDIAL EFFUSIONS. 

Effusions into the pericardial cavity, according to their char- 
acter, are known as hydropericardium, or hydrops pericardii, 
clear fluid in the pericardium ; hcemopericardium, blood in the 
pericardium ; pyopericardium, pus in the pericardium ; and 
pneumopericardium, when there is air in the pericardium. 

DISEASES OF THE HEART. 

It is now believed that both contraction and dilatation of 
the arteries and heart are active processes. In embryonic 
life an aggregation of cells takes place in the middle germinal 
layer, which forms a network in the area pellucida. Within 
these cells, cavities develop, the primary capillaries, from 
which there are offshoots, the secondary vessels, which trav- 
erse the body as bloodvessels. The heart, which has been 
aptly described as a quadruplication of the bloodvessels, is de- 
veloped later. 



HYPERTROPHY AND DILATATION OF THE HEART. 297 



ATROPHY OF THE HEART. 

Atrophy of the heart may be partial, involving only a part 
of the heart ; or complete, involving the whole heart. 

Etiology : Sometimes the condition is congenital. A partial 
atrophy may be due to chronic endoperi carditis. Usually 
acquired atrophy of the heart is general, associated with gen- 
eral wasting of the body. Thus we find atrophy of the heart 
in the marasmus of phthisis, cancer, diabetes, amyloid degen- 
eration of the kidneys, etc. The walls of the heart may show 
atrophy from arteriosclerosis. 

Atrophy — symptomatology : The hearfs action becomes 
weakened, the pulse feeble, the impulse of the heart dimin- 
ished. Usually other evidences of marasmus are present. 
The area of heart-dulness is diminished. With weakness of 
the heart muscle the first sound becomes muffled and may 
not be heard ; the second sound may be accentuated. 

Diagnosis : Is made by the marasmus, atropliy of other 
organs, weak heart-action, and diminution of the area of 
heart-dulness. 

The prognosis takes color with the cause. The immediate 
outlook depends upon the condition of the heart. 

Atrophy — treatment : This should address the cause. A 
flagging heart calls for the judicious use of heart-stimulants. 
Probably one of the best is strychnine. Above all, the indi- 
vidual should live a pleasant life in an abundance of fresh 
air and sunshine. 

HYPERTROPHY AND DILATATION OF THE HEART. 

Cases of hypertrophy of the heart may be divided into (1) 
hypertrophy caused by some obstruction tvitJnn the heart, 
especially valvular disease ; and (2) so-called " idiopathic " 
hypertrophies, the cause of which may be : («) disease of the 
heart-muscle, especially infection, over-strain and degenera- 
tion ; (b) some obstruction in the vascular system outside of 
the heart, especially arteriosclerosis ; and (c) affections of 
the nervous system. 

In some cases the cause may not be found, when the condi- 



298 DISEASES OF THE OMGANS OF CIRCULATION. 



tion may be properly classed as a cryptogenetic hypertrojohy. 
Hypertrophy is caused by some obstruction to the circiila- i 
tion, and is compensatory so long as it overcomes the ob- 
stacle. 

Diseases of the heart-muscle Avhich may cause hypertro])hy 
and dilatation of the heart are: (1) fatty degeneration; (2) 
myocarditis; (3j tumors of the heart (myomata^ cysts, malig- 
nant growths) ; and (4) parasites (cysticerci, echinococcijo 

Resistance within the vascular system, ^Yllich may cause 
hypertrophy and dilatation of the heart, may be due to : (1) 

Fig. 34. . 

! 




Suyjerficial cardiac dulness (approximate) (Flint). 

congenital contraction of the vessels ; (2) arteriosclerosis; (3) 
muscular effort (hard work, strain) ; (4) plethora (excess in 
eating and drinking) ; (5) pregnancy ; (6) disease of the kid- 



HYPEBTROPHY AND DILATATION OF THE HEART 



ney (Bright's disease); (7) diseases and deformities of the 
chest femphvsema, kyphosis). 

Among the affections of the nervous system that may cause 
hypertrophy and dilatation of the heart are : (1) mechanical 
irritation of the vagus nerve (tumors, enlarged lymphatic 
glands, Basedow's disease); (2) chemical irritation of the vagus 
(alcohol, tobacco, coffee, tea) ; (3) psychic irritation (domestic 
troubles, business worries) ; (4) excess in venery. 

Symptomatology : Hypertrophy of the heart is indicated by 
increased pulse-tension, dislocation of the apex-beat to the left, 
inci'ease of the impact of the heart and dulness, accentuation 
of the second aortic valve sound. The increased blood-supply 
may cause headache, epistaxis, and polyuria. 

Diiafation of the heart is indicated by the signs of a failing 
heart, frequent and small pulse, dyspnoea, bronchitis, asthma, 
headache (caused by anaemia of the brain), and oedema, first 
of the ankles and eyelids, sometimes of the lungs, wdiich may 
finally amount to anasarca. 

Dilatation may cause a valve to become insufficient in the 
absence of any disease of the valve itself. Such relative in- 
sufficiency or incompetency is most frequently found in the 
tricuspid valves, due to dilatation of the right ventricular 
orifice, most frequently the result of mitral regurgitation. In 
such cases a bruit may be heard over the ensiform cartilage. 

Diagnosis : The symptoms of most value in the diagnosis 
of hypertrophy of the heart are : (1) the dislocation of the 
apex to the left; (2) accentuation of the second aortic valve 
sound ; (3) increased cardiac impact and dulness; (4) the full 
pulse ; and (5) evidence of increased blood-pressure in various 
organs (headache, epistaxis, polyuria). 

Dilatation of the heart is recognized by the weakened heart's 
action, frequency of the pulse, tachycardia, palpitation, dysp- 
noea upon sliglit exertion, reduction in the quantity of urine, 
with usually enlargement of the liver, later oedema. Soon 
the urine assumes the character of the urine of stasis — high 
colored, containing hyaline casts. 

Most important is the discovery of the cause : syphilis^ 
alcohol, Bright's disease, tobacco, coffee, tea, valvular dis- 
ease, etc. 



DISEASES OF THE ORGANS OF CIRCULATION. 



The differential diagnosis concerns especially (1) pericardi- 
tis, in which the area of dulness takes the form of the peri- 
cardial sac, with the base upward ; the impact of the heart 
and the apex-beat are weak and sometimes may not be felt 
upon palpation ; and there are the characteristic friction-sound, 
fever, pain, etc. ; and (2) aneurism of the aorta, in which there 
is the aueurismal bruit or thrill. The heart may be hyper- 
trophied in cases of aneurism of the aorta. 

The prognosis depends upon (1) the condition of the heart. 
In compensatory hypertrophy the prognosis is good. The out- 
look becomes bad when the hypertrophy gives way to dila- 
tation. 

(2j The prognosis depends largely upon the cause. The 
prognosis is good in the hypertrophy of pregnancy ; but preg- 
nancy may make the prognosis worse when it occurs in the 
course of disease of the heart. The outlook is not bad in 
hypertrophy due to excess in venery, or the abuse of tobacco, 
tea, or coffee, if such excess or abuse be discontinued. The 
prognosis is more grave in arterio-sclerosis and Bright^s disease. 

(3) The prognosis takes color with the occurrence of cer- 
tain symptoms : ursemia, cyanosis, and tachycardia are grave 
signs. 

(4) The outlook is bad when the heart no longer responds 
to digitalis or other heart-stimulants. 

Prophylaxis : Care should be exercised not to break down 
an hypertrophy that is compensatory. This calls for control 
of the emotions, especially worry, anger, and fear ; and avoid- 
ance of excesses, strains, and exposures. 

Treatment: Tumultuous action of the heart may be con- 
trolled by rest and cold applications (cold compresses, ice-bag) 
over the heart, and the administration of the bromides, 
sodium bromide, gr. xx-xl in a glass of water, or Selters 
water. 

The symptoms of dilatation call for rest, best in bed in the 
recumbent posture, whereby the greatest relief is obtained 
from dyspnoea, palpitation, and heart-failure. 

Upon recovery of the tone of the heart, marked by im- 
provement in the pulse and an increased secretion of urine, 
judicious exercise of the heart-muscle may be recommended. 



MYOCARDITIS. 



301 



Such exercise is secured by very gradual increasing gymnastic 
exercise, best in the open air, but never continued to the point 
of fatigue. Contraindications to such exercise are acute myo- 
carditis and acute dilatation of the heart. 

The diet should be light and nutritious, and may consist 
largely of milk. 

Compensatory hypertrophy should not be interfered with by 
the administration of heart-stimulants. With the breaking 
of compensation heart- stimulants become useful. Digitalis 
stands first. In mild cases the tincture of digitalis, gtt. v-x, 
may be given every three or four hours ; in more severe cases 
the infusion of digitalis, teaspoonful to a tablespoonful at the 
same intervals. Digitalis is probably more effective in the 
form of the powder, a grain every two to six hours. 
Sooner or later digitalis disturbs the stomach, when it may be 
substituted by the tincture of strophanthus, gtt. v-x every 
three or four hours, or the sulphate of sparteine, in the same 
dose as the sulphate of morphine. The heart may be sup- 
ported for a long time by strychnine, in the form of the tinct- 
ure of nux vomica, gtt. x-xx, or of the sulphate or nitrate of 
strychnine, gtt. x of a grain-to-the-ounce solution three times 
a day. The sodium benzoate of caffeine, gr. iij-v, especially 
W'hen injected subcutaneously, acts more readily. Nitroglycerin 
is especially valuable in the cases due to kidney disease 
(see Treatment of Heart-failure). 

Further treatment is symptomatic. 

MYOCARDITIS. 

Inflammation of the myocardium, heart-muscle, may be acute 
or chronic ; circumscribed or diffused ; parenchymatous, in- 
volving chiefly the muscular fibres ; or interstitial, involving 
chiefly the interstitial tissue. 

Etiology : OircumsGrihed myocarditis may be caused by em- 
bolism in the coronary artery or its branches, or by septicsemia. 
The disease is often associated with ulcerative endocarditis, 
puerperal fever, malignant pustule, acute articular rheumatism, 
diphtheria, or typhoid fever, and with purulent or gangrenous 
affection of the lunffs. 



:',()2 />/,s7';,i-s7';<s' o/'' rni': o/.v/zIms' of ('iikujla'iion. 



Aciilc difl'tirc ni iiocardilh', vvlicllicr |>;ii-ciicliym;il()iis oi" 
Htiiinl, iiHiiiilly is <':nisc<l I In- iiircclions, cHpecially sep- 
tiofi'liiifi, h'plioi*! level', <li|>lil liei i:i, |>neiim(mi;i, ;ni(l tnnior- 

(1ir<>ii(<' nii/(K'((r(//fif<:\\^(> m;iy depend upon llie iid'eel ions, 
(«speei;ilU' neiile nrl ieidni' i*lieiiiii;il ism, iii:d:i i i;i, sypliilis, l!,'oiH,, 
<li:il»el('s, I'.rii'lil's dise.'ise. M.'iiiy enses lire cmiiscmI by jilcoliol, 
Inh.iceo, ;nid le.id. ri'()|)ably niosi. <\'ises ;i re ;iseril)ed io cold, 
I r;iiiiii;i, or s( r;iin. M yodiirdltiH IH iTe(|iieii(ly due Io Hie cx- 
Iriisioii of iiill;iiiiiii;il ion I'roin Hie oiidocardiiim (U' pcricjirdiiiin. 

Syinpt/ouin.tology : Syinploiiis of myoe;irdil is iiiiiy Ix; ;il)senl/ 
or o\'crsli;ido\ved by ciidoeiird ills or pei ie.irdil is. As :i riilo, 
llie lie;ir(i is nol. :i,ble Io do ils worl^ so well. SliHjit cxei-tion 
VAWl^r.^ l>(ffl>il<i/i<>n :iiid s/iorl iicss oj i>rc(i//i. Tliere IWliy ho pd ill 
in tJic reunion *>\ llie lie:irl, e\leiidin<.'; Io (lie ri«dil ;irin or epi- 
g'lisirio l'^'u;'ion. riie ;ipe\ l)e;i(, iiiip:ie| n( (lie lie;ir(, :nid (lie 
liCMrt-soiinds aro \V(!akeiied, indieal in;;' .i ircah licarl. 'V\\v, 
puhc be(M)nios uicak and iri'iyii/dr. P're* jiicnl b' (lie rcspi- 
r<i/(>ri/ fKlssfU/CK ^^\ni\\ ('<if<t rr/i. /h(/(slnni is ini|»;iife<l. AN (lie 
or!''ans sirn'ci' IVoni (lie poor blood siippb . The iii<li\ idiial is 
ci/ii m>( /<', Tlie \'ems(»l (lie neck are dis(ciided. 

The (lia^^DOMiH resis eliielly on llie e\ idene(« of a weak heart 
and (he his(or\' of some disease (lia( \\\:\y \)\'d\ i\ rnic in 
el iolo!j;\'. 

'I^lie proKiioHiK is al\\ a\ s <';ra\ (', bn( reeo\cr\' i'-^ I he riilr. 
The oiidook is beller in (n plioid IcNcr (lian in searlel lex'er or 
diphdieria. The oeeiirreii<'<> of pei iea rd i ( is or eiidoeardilis 
a<lds (o ( he <j;ra\'i(\' ol a ease. l lie prognosis , is bad in 
r>ri;;h('s disease, P'ailnre (d" di<>i(alis is a bad si!.'ii. 

PropliylaxiK : The pal ieni should (ak<> \ ci n careriilb' !.';radn- 
a(ed exercise diinii;:; eon\aleseenee iVoin (he inleelions <lipli 
(heria, (\phoid (e\'er, e(e. Mxeesses in i-n niiias( ies, \('ner\', 
drinkiii<;' (espeeialh' alcohol ), a nd caliiiij,' should be a\<»ided. 
As lar as possible Ihc inleelions and obcsily should be pre 
venlcd. Th(» prop(M* I real mcnlol' Hie inleel ions will do much 
<o less(>n Mie nnmber of ca^;es of myoeardilis. 

Troatmont : 'IdiepalieiH \\i(li dcuh' in i/oiut nlil is sh(»iil(l ob 
ser\-c absoliile resi in bed, and iiol arise I'lMin Ihc reeiiinbeni 
pos(iii-(> nnd(>r any prelcxi. This implies Ihc use ol' Ihc IkmI- 



ENDOCARDITIS. 



303 



pan, and not permitting tlie patient to sit up when being ex- 
amined. The best single article of diet is milk, to which may 
be added fruit, fish, and the white meat of fowl. The supper 
should always be light, consisting only of a glass of warm 
water or weak tea. 

In chronic myocarditis the patient should take carefully 
graded exercise, best in the open air. Such exercise delays or 
stops degeneration of the muscular fibres of the heart. Some 
times a change of climate is advisable. Bad cases may prefer 
the seashore, especially during the summer. It may be better 
to go to a warmer climate during the cold months. With 
improvement or with the beginning of treatment in light 
cases the heart may be given additional exercise by altitude, 
Nvhich at first should not be too higli. 

Cases of emphysema, asthma, and chronic bronchitis should 
lead neither a too active nor a too indolent life. 

The effect of toxins upon the heart is met by quinine, gr. iij 
every three or four hours. The heart should be supported 
by strychnine, best hypodermatically. Further support of 
the heart calls for digitalis and the treatment given under 
Heart-failure. The sulphate of sparteine, gr. \, may be 
given hypodermatically several times a day ; or camphor 
dissolved in oil or ether, hypodermatically ; or the sodium 
benzoate of caffeine, internally or hypodermatically. Friction 
of the skin, especially of the extremities, hot applications, 
and mustard-plasters address the heart. The hot bath may 
be used when the heart is weak ; in other cases the use of 
the cold bath daily gives relief to the patient and strengthens 
the heart. 



ENDOCARDITIS ^ Acute Simple Endocarditis; Septic Endo- 
carditis). 

Etiology: Endocarditis is a secondary process, occurring in 
the course of or following some infectious disease, due to the 
invasion of the endocardium, or lining membrane of the 
heart, l)y micro-organisms, a number of which liave been 
demonstrated, among them the micrococcus pneumoniae 
crouposDe, streptococcus pyogenes, staphylococcus pyogenes 



304 DISEASES OF THE ORGANS OF CIRCULATION. 



aureus, bacillus diphtherise, the gonococcus, and the tubercle 
bacillus. 

In experiments upon animals it has been shown that the 
injection of micro-organisms into the circulation is not fol- 
lowed by endocarditis unless the heart is first subjected to 
traumatic or chemical injury. This would seem to explain 
the role played by trauma, exposure to cold, arteriosclerosis, 
and atheroma. 

Endocarditis is especially likely to appear in the course of, 
or after, rheumatism, pneumonia, influenza, septicaemia, in- 
cluding surgical sepsis and puerperal fever; also osteomyelitis, 
periostitis, erysipelas, furunculosis, and dysentery, gonorrhoea, 
scarlet fever ; less frequently smallpox, measles, typhoid 
fever, syphilis, Bright's disease, and malaria. Sometimes 
even trivial atfections (quinsy, mumps) may be accompanied 
or followed by endocarditis. The endocarditis may be due 
to invasion by the specilic micro organisms of the infectious 
diseases, or to secondary infection, or to the effect of toxins. 

Acute endocarditis — symptomatology : As a rule the onset is 
insidious, and the disease may remain unrecognized for a long 
time. As long as the inflammation is limited to the wall of 
the heart there may be no signs of the disease appreciable 
during life. Affection of the valves may occur without signs. 
Usually the valves are aflected and the signs of the disease 
present ; but frequently they are overlooked through failure 
to examine the heart. 

Exceptionally endocarditis is announced suddenly by severe 
pain in the heart, dyspnoea, and cyanosis, rapid and irregular 
action of the heart. Such symptoms may follow sudden 
strain, with rupture of a diseased valve. 

Suspicion may be aroused by irregular fever. But in some 
cases there is no fever. The pulse is irregular and rapid. 
There is palpitation, especially upon exercise or emotion. 
Headache, insomnia, and anorexia are common symptoms. 
The spleen is enlarged, hard, and tender. There may be en- 
largement and tenderness of the liver, such as occur in the 
infections. There is tenderness upon pal])ation over the region 
of the kidneys. The urine is high-colored, and may contain 
blood, albumin, casts, and micro organisms. 



MYOCARDITIS. 



305 



The detacliment of thrombi may give rise to embolism of 
distant organs. Little damage is caused by the plugging of a 
vessel by an aseptic embolus^ where collateral circulation may 
be readily established. More serious is the occlusion of end- 
arteries in the brain, lung, spleen, kidneys, etc., especially by 
septic emboli. 

Endocarditis — physical signs : Inspection and palpation 
may reveal an increased or decreased action of the heart. 
Percussion later shows an increase of the heart-didness. More 
valuable evidence is chained throuo^h auscultation, even earlv 
in the course of the disease. The affection of valves causes 
various anomalies of sound. The inifral cat re, for Avhich en- 
docarditis show- a preference, is usually rendered instifficient, 
with the producti'in of a bruit synchronous with the systole 
or hrst sound of the heart and heard with greatest inten- 
sity at the apex. When the heart is very weak the murmurs 
and also the first sound of the heart may be absent. The 
mitral valve may be aifected in such a ^vay as to cause sten- 
osis, when the murmur woidd be pre^y.-t 'lie. With hyper- 
trophy of the heart the valve-sounds become accentuated. 

Diagnosis : The symptoms ustially of most value in diag- 
nosis are chill, fever, pain in the region of the heart, palpita- 
tion, anxiety, headache, insomnia, and dyspncea. Sometimes 
the semirecumbent posture asstimed by the patient may excite 
suspicion of the presence of endocarditis. Upon physical ex- 
amination the heart's action may be found increased or de- 
creased, the apex-beat displaced, the heart-dulness increased, 
and there may be murmurs indicative of valvular disease. 
The history or knowledge of the existence of one of the infec- 
tions, especially acute rheumatism, septicaemia, pneumonia, or 
tuberculosis, may aid in an individual case. 

The differentiation between sim])]e and -eptic endocardi- 
tis may sometimes Ije made by a bacteriological examination 
of the blood and urine. Evidences of stenosis of a valve 
would indicate chronic endocarditis, as does also affection of 
the valves at the base of the heart and of the right side of 
the heart, except when congenital. Evidence of tricuspid 
insufficiency would point to chronic endocarditis. Affection 
of the mitral valve, causing a murmur most intense at the 



305 DISEASES OF THE ORGANS OF CIRCULATION. 



apex, usually soft blowing in character, and synchronous with the 
first sound of the heart, would be caused by acute endocarditis. 
Relative insufficiency is usually due to acute endocarditis. 

Prognosis : The prognosis should be guarded, but is not 
necessarily fatal, even in the presence of grave complications. 
The outlook is bad in malignant cases. Sometimes benign 
cases, especially in early lite, may entirely recover with the 
disappearance of even marked physical signs. More fre- 
quently acute cases become chronic. Cases of simple endo- 
carditis usually recover. The prognosis is always worse in 
septic cases, especially when due to the streptococcus pyogenes. 
Complications, especially embolism, add gravity to the prog- 
nosis. 

Endocarditis — treatment : Rest in bed must be absolute. 
The diet should be light — milk, malted milk, and the gruels. 
The sick-room should be well ventilated ; the bed-clothing 
light but adequate. Unnecessary visitors should be excluded. 
Treatment should, if possible, be addressed to the underlying 
cause, usually one of the infections. In the presence of rheu- 
matism or infection by the micrococcus pneumoniae crouposse, 
sodium salicylate may be administered, gr. v-x every two to 
four hours, best with whiskey or brandy. Palpitation that 
causes distress may be relieved l>y cold compresses over the heart. 
Phenacetin, gr. iij-v, may be given to quiet excessive action 
of the heart and relieve pain. More severe pain may be met 
with opium, best in the form of Dover's powder, which may 
be given to children in the form of the syrup. Exception- 
ally morphine is required. A flagging heart demands stimu- 
lation (see Heart-failure). 

In septic cases, the original depot of infection should be de- 
stroyed, if possible. Curetting may be required for endome- 
tritis ; deep urethral injections for posterior urethritis, prosta- 
titis, cystitis ; (;limate and tuberculin for tuberculosis ; exsec- 
tion for osteomyelitis. 

SCLEROTIC ENDOCARDITIS (Chronic Endocarditis; Chronic 
Valvular Disease; Atheroma). 

Etiology : Usually sclerotic endocarditis results from an 
acute endocarditis. An important role in etiology is played 



SCLEROTIC ENDOCARDITIS. 



307 



by strain of the heart in overcoming obstruction offered to the 
circulation by arteriosclerosis, Bright's disease, etc. Muscu- 
lar exertion may rupture a yalye or one or more of the chordse 
tendinese through distention of the heart ; but such an acci- 
dent usually can occur only wlien the yalyes or chordse ten- 
dinese haye been preyiously weakened by disease. Frequently 
a weak heart seems to be inherited. 

Symptomatology : As in acute endocarditis, the inflamma- 
tion may be confined to the wall of the heart and symptoms 
be altogether absent. Such cases are recognized first upon 
autopsy ; or the nature of the disease may be suspected upon 
detachment of particles of a thrombus producing eniholimi in 
yarious parts of the body, especially the brain, retina, lungs, 
spleen, kidneys, organs in which there are endarteries. Rarely 
the yalyes may be affected without signs of the disease. 
Oftener the eyidence of affection of the yalyes is overlooked 
because disease of the heart is not suspected. 

The general symptoms of sclerotic endocarditis are due 
largely to the condition of the heart-miiscle. There are failure 
in the general health, a lack of zest, early fatigue, palpitation, 
and rapid pulse and respiration upon slight exertion. The 
mitral yalye is most frequently affected ; there may be dysp- 
noea, and the individual " takes cold " easily, due to the dis- 
turbed nutrition. Sometimes there are cough, hsemoptysis, 
chilly sensations, sweats, loss of weight, ansemia — resembling 
very much the picture of tuberculosis. Frequently there is 
dyspepsia, which may be the chief complaint. Sometimes 
there is oedema, especially about the ankles, which may be the 
first symptom noticed by the patient. With the breaking of 
compensation the pulse becomes irregular and weak. 

The remote or secondary symptoms of sclerotic endocarditis 
dependupon : (1) Defectiveblood-supply, evidenced by faintness, 
vertigo, syncope, early fatigue, increased secretion of uric 
acid. (2) Stasis, the dropsy first appearing about the ankles 
and extending over the body. There are increased frequency 
of the respiration, catarrh, dyspnoea, in bad cases cyanosis and 
haemoptysis; hebetude, headache, later delirium and coma, 
and in extreme cases oedema of the brain. With insufficiency 
of the tricuspid valve there are dilatation and throbbing of the 



308 DISEASES OE THE ORGANS OE CIRCULATION. 



jugular veins and other veins in the neck; the liver may 
show pulsation, which is more perceptible upon palpation. In 
the liver there is an increased formation of connective tissue ; 
the organ at first becoming enlarged, and later the connective 
tissue contracting to constitute a true cirrhosis (cardiac cir- 
rhosis). Extreme stasis causes the so-called "nutmeg liver.'^ 
The kidneys become congested and enlarged, the urine dim- 
inished in quantity, sometimes amounting to anuria ; in pro- 
tracted cases the kidneys become cirrhotic. Affection of 
the stomach causes dyspepsia, anorexia, gastrectasia, etc. ; 
affection of the intestines, chronic catarrh, constipation, hemor- 
rhoids. (3) Embolism does not occur so frequently as in acute 
endocarditis. 

Prognosis and treatment : See Valve-lesions. 

VALVULAR DISEASE. 

The valves are said to be insufficient or incompetent when 
they fail to close the opening so as to prevent a reflux of blood. 
In stenosis the valves offer obstruction to the normal flow of 
blood through the orifice. 

In " relative " insufficiency the valves may remain normal ; 
but the opening they guard is increased in size, through dila- 
tation of the heart, so the valves are no longer able to prevent 
the return flow of blood. 

Mitral Insufficiency. 

Definition : A condition of the valves guarding the left 
auriculo-ventricular orifice, thnt permits some of the blood to 
return to the left auricle upon contraction of the left ventricle. 

Etiology : The most frequent cause is endocarditis. Other 
causes are atheroma, myocarditis, fatty heart, and neoplasms. 

Mitral insufiiciency — symptomatology : A systolic murmur, 
synchronous with the first sound of the heart, is heard with 
greatest intensity at the apex. Sometimes this bruit is heard 
most distinctly toward the end of systole with the last forci- 
ble contraction of the left ventricle. Sometimes the sound 
seems to be continued into the second sound, constituting the 
souffle paradoxal (Paul), so named because of its resemblance 



VALVULAR DISEASE. 



309 



to a true diastolic murmur. A better term probably is j)re- 
diastolic (Fraentzel). A long auricular appeudage sometimes 
causes the murmur to be heard with equal intensity at the 
base of the heart, about two inches to the left of the region 
of the pulmonary valve-sound. 

Regurgitation of blood through the mitral orifice into the 
left auricle, causes hypei'trophy of the left aiiricle, which soon 
gives way to dilatation. Dilatation of the left auricle may 
cause the heart-dulness to extend upward as high as the second 
rib. The obstruction to the circulation increases the blood- 
pressure, not only in the left auricle, but also backward 
through the pulmonary veins and the pulmonary artery, to 
cause accentuation of the pulmonary valve-sound. 

The pulmonary valve-sound is heard best to the left of the 
sternum, at the second costo-sternal junction or in the second 
interspace. Accentuation of the pulmonary valve-sound may 
also be caused by obstruction to the circulation in the lungs 
or by arterio-sclerosis. When hypertrophy of the right ven- 
tricle gives way to dilatation, accentuation of the pulmonary 
valve-sound may no longer be heard. 

The extra work caused by the increased blood-pressure in 
the pulmonary artery causes hypertrophy of the right ventricle. 
The heart-dulness extends beyond the right border of the 
sternum. Hypertrophy of the right ventricle may compen- 
sate for a long time for the defect in the mitral valve. With 
hypertrophy of the right ventricle the heart comes to lie more 
upon its side and a larger surface rests upon the diaphragm, 
so that pulsation of the riglit ventricle may often be felt at the 
ensiform cartilage. The apex is dislocated to the left. Some- 
times the right ventricle comes to form the apex of the heart. 

Later, compensation is broken, the hypertrophy of the right 
ventricle giving way to dilatation. The action of the heart be- 
comes weaker, the pulse, cardiac impact, and apex-beat less jjer- 
ceptible. Relative insufficiency of the tricuspid valve may 
give rise to pulsation in the liver and the veins of the neck. 

Mitral Stenosis. 
Definition : Obstruction of the left auriculo-ventricular 
orifice. 



310 DISEASES OF THE ORGANS OF CIRCULATION. 



Etiology : Mitral stenosis is most frequently due to endo- 
carditis ; rarely to aneurism in the wall of the ventricle or of 
the valve ; very rarely to neoplasms. Stenosis occurs often in 
early life and has been found at birth. 

Symptomatology : Obstmction is offered to the circulation at 
the left auriculo- ventricular orifice. The symptoms bear a 
marked resemblance to those of mitral insufficiency. Insuffi- 
ciency of the mitral valve is frequently present in mitral ste- 
nosis. Stasis in the lungs gives rise to shortness of breath upon 
slight exertion^ such as climbing stairs. The individual^ate 
cold upon every exposure. There are cough, expectoration of 
frothy mucus, and sometimes haemoptysis. Lessened blood- 
supply to the brain is evidenced by lack of concentration of the 
mind, apathy, and emotional disturbances. At first the surface 
is pale, the mucous membranes anaemic ; later there are 
venous stasis, cyanosis, icterus, and dropsy, first appearing 
about the feet. 

The obstacle to the circulation offered by the diminution in 
size of the left auriculo- ventricular orifice causes increased 
blood-pressure within the left auricle, which is met at first by 
hypertroj)hy of the left auricle. This soon gives way to dila- 
tation. The blood-pressure is increased within the j)uhnonary 
vessels and lungs, which early interferes with the aeration of 
the blood, causing cyanosis and predisposing the individual to 
catarrh of the respiratory apparatus and hemorrhage. The 
increased blood-pressure within the pulmonary artery causes 
distinct accentuation of the pulmonary valve-sound.. The sec- 
ond sound is frequently split. The right ventricle undergoes 
rapid hypertrophy, and more readily becomes dilated than in 
mitral insufficiency. The fremissement cataire of Laennec, 
a peculiar presystolic or diastolic vibratory thrill, may be felt 
over the heart. As in mitral insufficiency, dulness may ex- 
tend upward to the second rib and beyond the right border 
of the sternum. The murmur, which is heard in greatest 
intensity at the apex, is presystolic — that is, occurs just before 
the second sound of the heart. Hypertrophy of the right 
ventricle causes accentuation of the tricuspid valve-sound, heard 
best over the ensiform cartilage, which disappears upon dila- 
tation of the right ventricle. 



VALVULAR DISEASE. 



311 



Dilatation of the pulmonary artery may result in relative 
iiisufficieaci/ of the pulmonary (semilunar) valves^ producing a 
diastolic murmur heard in greatest intensity over the third or 
fourth left interspace near the sternum. With dilatation of 
the right ventricle the tricuspid valves become incompetent, 
with consequent venous sta.sis, and pulsation of the veins in 
the neck. The liver becomes enlarged and may show pul- 
sation. 

On the part of the kidneys, the urine becomes diminished 
in quantity, high in color and specific gravity, and contains 
albumin. The action of the heart becomes weak, as is evi- 
denced by the pulse, which becomes weak, irregular, and in- 
termittent. 

Aortic Insufficiency. 

Definition: Imperfect closure of the aortic orifice, permit- 
ting regurgitation of blood from the aorta into the left ven- 
tricle. 

Etiology : Insufficiency of the aortic valves is due to endo- 
carditis or the process of arterio-sclerosis or atheroma. 
Dilatation of the aorta (aneurism) may give rise to relative 
insufficiency of the aortic valves. 

Aortic insufficiency — symptomatology : Usually the onset is 
insidious. Frequently insufficiency of the aortic valves exists 
for a long time unrecognized. The first symptoms complained 
of by the patient may be nervousness, palpitation, pain, ver- 
tigo. Sometimes the onset is sudden, especially when the in- 
sufficiency is induced by severe strain, and is announced by 
precordial pain, intense dyspnoea, a diastolic murmur, and 
accentuation of the sec(md aortic sound. The change from 
hypertrophy to dilatation is marked by the symptoms of 
heart-failure. Early symptoms are vertigo, headache, insom- 
nia. There is pulsation of the carotids. There may be dis- 
ease of the kidneys. Cerebral hemorrhage may be caused by 
arteriosclerosis or embolism. Hypertrophy of the right ven- 
tricle prevents for a long time symptoms on the part of the 
lungs. Later there may be attacks of dyspnoea, appearing 
first only upon exercise. 

Inspection and palpation may reveal enlargement of the 



312 DISEASES OF TitE ORGANS OF CtRCtlLATtON. 



hea7't, often to such a degree as to constitute the cor hovinum^ 
or ox heart," due to hypertrophy of the left ventricle. The 
cardiac impact is increased. The heart throbs. 

Dulness may extend from the right border of the sternum 
to the left mammary line and from the second to the sixth 
rib. 

With beginning faihire of the left ventricle to perform its 
unusual labor, extra work is required of the left auricle, which 
soon gives way under the strain to cause increased blood- 
pressure in the pulmonary veins, lungs, pulmonary artery, and 
the right ventricle. 

The 7'ight ventricle becomes hypertrophied and adds to the 
enlargement of the heart, which is caused chiefly by hyper- 
trophy of the left ventricle. 

Later the hypertrophy of the left ventricle may relieve the 
right ventricle of its extra work and cause the lung-symptoms 
to disappear. A murmur, synchronous with the second sound 
of the heart — therefore diastolic, sometimes pre-diastolic — is 
heard most distinctly upon the right of the sternum in the 
second or third intercostal space. The blood-pressure in the 
arteries is not long sustained by the aortic valves, and the 
pulse rises and falls abruptly with the beating of the left 
ventricle, constituting the cannon-ball pulse, first described 
by Corrigan, of Dublin, in 1830, and sometimes called Corri- 
gan's pulse. 

Aortic Stenosis. 

Aortic stenosis is most frequently due to arterio-sclerosis 
or atheroma extending from the aorta to involve the aortic 
valves. The valves become thickened or calcified. Some- 
times aortic stenosis is due to endocarditis, usually as an ex- 
tension of the process which has first involved the mitral 
valves. Aortic stenosis is more common in age, but has been 
found at birth. Aortic stenosis rarely occurs alone — that is, 
without other diseases of the valves. 

Aortic stenosis — symptomatology : Obstacle is offered to the 
exit of blood from the left ventricle, causing increased blood- 
pressure tvithin the left ventricle, ivith consequent hypertrophy. 
The hypertrophy is not so great as in aortic insufficiency. The 



VALVULAR DISEASE. 



313 



apex-beat is displaced but little to the left, and appears in 
the sixth intercostal space. The action of the heart is stronger 
than normal. The impact of the heart is increased. ith 
failing of compensation, the left ventricle becomes dilated, 
sometimes to such an extent as to cause relative insuffi- 
ciency of the mitral valves. There follow hypertrophy and 
dilatation of the left auricle, increased blood-pressure in the 
pulmonary veins, lungs, and pulmonary arteries, and hyper- 
trophy of the right ventricle, which may later give ^vay to 
dilatation to cause insufficiency of the tricuspid valves. 

A fremitus or thrill, tlie fi-emitus cataire, may be felt upon 
the right of the sternum over the second intercostal space, 
synchronous with the first sound of the heart, therefore sys- 
tolic. A murmur is heard wdth greatest intensity over the 
second intercostal space to the right of the sternum, also 
synchronous with the first sound of the heart or systole. The 
second sound of the heart is feeble, in the absence of insuffi- 
ciency of the valves. The pulse is slotv, small, and iciry. 

Tricuspid Insufficiency. 

Insufficiency of the tricuspid valve is due to endocarditis or 
atheroma, and usually occurs in connection with affection of 
other valves. In the foetus, the tricuspid valves are most fre- 
quently afPected, probably because most work is thrown upon 
them. In extra-uterine life insufficiency of the tricuspid 
valves is due, as a rule, to relative insufficiency, caused by 
dilatation of the right ventricle. 

Tricuspid insufficiency — symptomatology : The heart is en- 
larged, especially toward the right ; there is distinct pulsation 
at the ensiform cartilage or in the epigastric region. Hyjoer- 
trophy gives way to dilatation sooner than in mitral insuffi- 
ciency. A murmur may be heard in greatest intensity at the 
ensiform cartilage. The second pulmonary sound is weak. 
Weakening of the accentuated pulmonary valve-sound in 
disease of the mitral valves indicates complicating insuffi- 
ciency of the tricuspid valves. There is venous pulsation, 
especially in the jugular and subclavian veins, observable first 
at the root of the neck in the bulb of the jugular vein. The 



I 



314 DISEASES OF THE ORGANS OF CIRCULATION. 



venous pulse is presystolic-systolic. Upon overcoming the Eus 
tnchian valve ])ulsation appears in the liver and in the femoral 
veins. Thei'e may be cardiac cirrhosis of the liver and 
spleen. With weakening of the action of the right ventricle 
the blood-pressure becomes lowered. The supervention of 
stasis is marked by ectasia of the veins, cyanosis, and cya- 
notic induration of the internal organs — lungs, liver, etc. 
Oedema becomes manifest first about the ankles, and mounts 
up the extremities and trunk. There are periodic attacks of 
dyspnoea, cardiac asthma, due to defective circulation and 
consequent defective oxygenation of the blood. 

Tricuspid Stenosis. 

Stenosis of the tricuspid valve, or obstruction at the right 
auriculo-ventricular orifice, occurs most frequently in the 
foetus. Occasionally cases have been reported in the adult, 
in the great majority of cases complicated with lesions of 
other valves, especially the tricuspid, mitral, and aortic. In 
the reported cases most of the patients have been of the female 
sex. Tricuspid stenosis in the foetus is believed to be due to 
endocarditis, the result of rheumatism ; a large proportion of 
the cases in the adult are due to rheumatism. Other cases are 
ascribed to the causes of disease of other valves. 

Symptomatology : The symptoms of tricuspid stenosis are 
frequently overshadowed by the lesions of other valves and 
myocarditis. There is extreme stasis with marked dyspnoea, 
cardiac asthma, and cyanotic induration of the liver, spleen, 
and kidneys. Icterus may be more or less pronounced. A 
diastolic bruit may be heard in the region of the ensiform 
cartilage. The right ventricle does not become hypertrophied 
in pure tricuspid stenosis, but rather undergoes atrophy. Ex- 
treme distention of the right auricle causes an increase in the 
heart-dulness. 

Pulmonary Insufficiency. 

Definition : Incompetence of the pulmonary valves, per- 
mitting the regurgitation of blc)od from the pulmonary artery 
into the right ventricle. 



VALVULAB DISEASE. 315 

Etiology : Insufficiency of the pulmonary valves is usually 
congenital. The condition may be acquired through endocar- 
ditis or arterio-sclerosis. Rarely cases may be due to trauma. 
A complicating pulmonary stenosis is the rale. 

Pulmonary insufficiency — symptomatology : Dyspnoea and 
cyanosis soon become apparent. Hypertrophy of the right 
ventricle may for a time compensate for or overcome the in- 
sufficiency of the puhnonary valves. Soon the right ventricle 
begins to fail and symptoms develop on the part of the lungs. 
Catarrhal symptoms and pulmonary hemorrhage appear early. 
Tuberculosis, which occurs frequently in these cases, is to be 
ascribed rather to an accompanying pulmonary stenosis. The 
heart-dulness i- increased, with hi/pertrophi/ of the right ven- 
tricle. The dulness may extend to or beyond the right bor- 
der of the sternum. The apex-beat is dislocated to the left. 
Systolic pulsation maybe readily recognized in the epigastrium 
and in the second intercostal space to the left of the sternum. 
A diastolic bruit, therefore, synchronous with the second sound 
of the heart, may be heard with greatest intensity in the second 
left intercostal space. Palpation may detect a diastolic fre- 
mitus or thrill. The ptilse is regular. 

Pulmonary Stenosis. 

Stenosis of the pulmonary valves is the most frequent con- 
genital defect of the vedves of the heart. The condition is 
rarely accpiired. Pulmonary stenosis is usually associated 
with other congenital anomalies, especially persistence of the 
foramen ovale and ductus arteriosus and perforation of the 
septum. Acquired cases occur usually in the course of 
endocarditis, after the affection of other valves. 

Pulmonary stenosis — symptomatology : Hypertrophy of the 
right ventricle causes dulness to become appreciable up to or 
beyond the rio-ht border of the sternum. There is epigastric 
pulsation. The apex-beat is slightly displaced. In the 
presence of perforation of the septum, some of the blood es- 
capes to the left side of the heart, causing more or less hyper- 
trophy of the left ventricle. Since the condition occurs in 
early life, there may be a distinct bulging of the chest. A 



316 DISEASES OF THE ORGANS OF CIRCULATION. 



miirinur, synchronous with the first sound of the heart, may 
be heard in the second left intercostal space. Congenital 
cases show cyanosis and usually arrested development of the 
body. Pulmonary stenosis predisposes the individual to 
tuberculosis, probably through imperfect development of the 
lungs more than through the defective blood-supply. 

Combined Valve-lesions. 

The following are the more frequent combinations: Insuf- 
ficiency and stenosis of the mitral valve ; insufficiency and 
stenosis of the aortic valve ; stenosis of the mitral valve with 
insufficiency of the aortic valve ; stenosis of the aortic valve 
with insufficiency of the mitral valves ; insufficiency of both 



Fig. 35. 




1, 2, 3, 4, location of valves ; I, II, III, IV, points where murmurs are heard in 
greatest intensity ; arrows indicate direction in which murmurs are propagated. 

mitral and aortic valves ; stenosis of both mitral and aortic 
valves ; tricuspid insufficiency with lesions of the mitral 
valve ; tricuspid insufficiency with insufficiency of the aortic 
valves; tricuspid stenosis with other valve-lesions. 

Diagnosis of valve-lesions : Accidental murmurs belong usu- 
ally to ansemia or cachexia. During compensation there is no 



VALVULAB DISEASE. 



317 



evidence of stasis or a failing of the circulation, notwith- 
standing the lesion in the heart. The breaking of compensa- 
tion is indicated by general degradation of health, loss of 
energy, inability to concentrate the mind, insomnia, headache, 
hebetude, sometimes vertigo, and symptoms on the part of the 
lungs. The pulse is increased in frequency and becomes 
weak. The surface of the body shows a lower temperature 
than normal. There is cyanosis ; the veins become distended ; 
there is enlargement of the liver and spleen. 

In the acUdt, the diagnosis of valve-lesions has to do almost 
exclusively with the left side of the heart, the mitral and aor- 
tic valves. Tricuspid insufficiency is of especial importance, 
since it is usually secondary to affection of other valves, and, 
as a rule, indicates a failing heart. 

Lesions of the right side of the heart, especially tricuspid 
stenosis and affections of the pulmonary valves, are congenital. 
Such lesions occur in early life, usually in association with 
other congenital defects. 

Valve -lesions — Physical and other Signs. 

Mitral insufficiency : (1) Systolic murmur, heard with great- 
est intensity at the apex. (2) Dilatation of left auricle, with 
dulness at the second rib to the left of the sternum. (3) 
Hypertrophy of the right ventricle, with dislocation of the 
apex-beat to the left, and dulness to the right of the sternum. 
(4) Accentuation of the second pulmonary valve sound. 

Mitral stenosis: (1) Presystolic murmur at the apex. 
Usually cases of mitral stenosis show also mitral insufficiency ; 
the murmur at the apex is then systolic and presystolic. (2) 
Dilatation of the left auricle, earlier and more complete than 
in mitral insufficiency, with dulness at the second rib to the 
left of the sternum. (3) Hypertrophy of the right ventricle, 
which gives way to dilatation sooner than in mitral insuffi- 
ciency ; dulness increased to the right of the sternum; dis- 
location of the apex-beat to the left and visible pulsation. 
(4) Accentuation and sometimes splitting of the pulmonary 
valve sound. 

Aortic insufficiency : (1) Diastolic murmur in the second right 



3] 8 DISEASES OF THE ORGANS OF CIRCULATION. 



interspace. (2) Marked, often extreme, hypertrophy of the 
left ventricle. Visible carotid pulsation. (3) Cannon-ball 
pulse. (4) Alcoholism or syphilis, prominent factors in the 
production of arteriosclerosis and atheroma, upon which aortic 
insufficiency usually depends. 

Aortic stenosis : (1) Systolic murmur in the second right in- 
terspace. (2) Hypertrophy of the left ventricle, with dislo- 
cation of the apex-beat downward and somewhat to the left. 
(3) Hard, wiry pulse. (4) Other diseases of the valves, es- 
pecially aortic insufficiency, with which aortic stenosis is often 
associated. 

Tricuspid insufficiency : (1) Systolic murmur in the region 
of the ensiform cartilage or epigastrium. (2) Dilatation of 
the right ventricle. (3) Venous pulsation, first observable 
upon effort, especially in the jugular bulbs and the liver. (4) 
Signs of a failing heart, cardiac asthma, cyanosis, edema ; and 
symptoms on the part of the lungs, especially cough, short- 
ness of breath, and hemorrhage. (5) Other diseases of the 
valves. Primary tricuspid insufficiency is sometimes encoun- 
tered in the foetus, but is very rare in adults. 

Tricuspid stenosis: (1) Presystolic murmur at ensiform 
cartilage. (2) Extreme dilatation of the right auricle. (3) 
General venous stasis. (4) Congenital ; rare. 

Pulmonary insufficiency: (1) Diastolic murmur in the second 
left interspace. (2) Hypertrophy and dilatation of the right 
ventricle. (3) Congenital ; rare. 

Pulmonary stenosis: (1) Systolic murmur in the second left 
interspace. (2) Extreme hypertrophy and dilatation of the 
right ventricle. (3) Cyanosis — " blue births.'' (4) The most 
common congenital lesion of the heart. 

Prognosis of valve-lesions : Diastolic lesions have a graver 
outlook than systolic lesions. 

The prognosis is most favorable in mitral insufficiency, es- 
pecially in childhood or when the lesion develops gradually. 
More grave is the outlook in aortic insufficiency, and still 
worse in aortic stenosis. 

The prognosis in mitral stenosis is almost as bad as in lesions 
of the right side of the heart. Tlie outlook is bad in tricus- 
pid insufficiency y which usually indicates dilatation of the 



VALVULAR DISEASE. 



319 



heart (relative insnfficieney). The outlook depends largely 
upon the response of the heart to cardiac stimulants, especially 
digitalis. 

The prognosis is bad in relative aortic insufficiency, be- 
cause the heart-muscle is weakened. Often there is arterio- 
sclerosis. 

Cyanosis and dyspnoea are bad signs, since they indicate a 
failing heart. A weak and irregular pulse is also ominous, 
when it may not be corrected by rest and heart-stimulants. 

The prognosis in embolism takes color with the situation and 
character of the embolus. The outlook is bad in septic em- 
bolism. Organic valvular disease is made worse by pregnancy. 
The prognosis is aggravated by tuberculosis. The outlook 
depends largely upon the condition of the heart-muscle, the 
habits and age of the individual, and his ability to take proper 
care of himself. The outlook is bad in alcoholics. Congeni- 
tal lesions of the valves of the right side of the heart give a 
bad prognosis. 

Prophylaxis of valve-lesions: The power of the heart-mus- 
cle should be conserved as much as possible. The individual 
must avoid the two extremes of over-activity and inactivity. 
In acute cases or during exacerbations the patient should ob- 
serve absolute rest in bed. With the establishment of a com- 
pensatory hypertrophy the heart must not be overtaxed. The 
individual should sleep more and work less, as a rule. The 
diet should be light and nutritious. In bad cases milk is the 
best diet. Sudden exertions and emotions and the use of 
heart-stimulants, including alcohol, tobacco, coffee, and tea, 
should be avoided. 

Treatment of valve-lesions : Heart-stimulants should be 
vnthheld so long as there is perfect compensatory hypertrophy. 
If possible, the cause should be discovered and properly 
treated. Arteriosclerosis, rheumatism, tuberculosis, etc., 
should be properly treated. Absolute rest in bed should be 
enjoined before complete compensation is established, and also 
in cases of breaking compuisation. In the presence of com- 
pensatory hypertrophy the individual should receive the in- 
structions given under Prophylaxis of Yalve-lesions, that the 
hypertrophy may be conserved. The patient should lead a 



320 DISEASES OF THE ORGANS OF CIRCULATION. 



pleasant, quiet life. A change to a warm climate may be ad- 
visable, especially during the winter and fall months. 

Some cases show marked improvement following the regular 
use of the warm bath. Constipation should be avoided ; the 
bowels should move once or twice a day. Much may be 
gained by carefully graded exercise, best in the open air, 
never carried to the point of exhaustion or strain. The 
heart-muscle is thus toned, just as any other muscle may be 
strengthened by exercise. Palpitation may be relieved by the 
application of cold, most conveniently in the form of the ice- 
bag or Leiter coil. Sometimes the patient may find it advisa- 
ble to carry a hollow tin shield or Bask filled with cold water 
in an inside pocket over the heart. Tumultuous action of the 
heart may sometimes be controlled by the bromides, especially 
sodiuQi bromide, gr. xx-xl. Pain varies greatly in intensity 
in different cases. Slight pain may be relieved by a mustard- 
plaster, or in more stubborn cases by a belladonna-plaster, or 
the administration of phenacetin, the salicylates, or salol. 
Severe pain may be relieved by morphine or the nitrates. 
Amyl nitrite, gtt. ij-v, may be inhaled from a napkin or 
handkerchief. Repeated attacks are prevented by the use of 
nitroglycerin, gtt. j-v of a 1 per cent, solution three or four 
times daily. A failing heart demands stimulation : strych- 
nine, caffeine, camphor, digitalis, or strophanthus. Dropsy 
that does not disappear upon rest may be relieved by caffeine, 
digitalis, or sodium salicylate, theobromine (diuretin), and the 
use of calomel. Extreme dropsy is relieved by puncture, 
probably best l)y one or two canulse in each lower extremity. 

Dyspnoea usually disappears under stimulation of the heart : 
camphor, valerian, or Hoffmann's anodyne. Pain and dysp- 
noea are both relieved at once by morphine, best given hypo- 
dermatically. 

NEUROSES OF THE HEART. 

A neurosis is a disturbance of function in the absence of 
any demonstrable organic lesion. The action of the heart is 
regulated to meet the requirements of the body by motor, 
vasomotor, and sensory impressions received through branches 



ARRHYTHMIA. 



321 



from the vagus, superior and inferior laryngeal nerves ; the 
cervical and first dorsal ganglia ; the pulmonary plexus, and 
occasionally from the descending part of the hypoglossus 
(Luschka). The sensory ganglia of the heart belong to the 
sympathetic system. 

ARRHYTHMIA. 

Arrhythmia, or irregular action of the heart, may vary from 
the occasional loss of a beat to the great irregularity known 
as delirium cordis. The pulsus higeminus is marked by the 
occurrence of two beats followed by an intermission ; the 
pulsus trigeminus^ by three beats followed by an intermission. 
The pulsus alterans consists of regularly alternating strong 
and weak beats. Various combinations exist. A pulsus 
bigemimis alterans would consist of a strong beat and a weak 
beat, followed by an intermission. The tremor cordis is 
marked by very rapid pulsation, giving one the impression 
of a vibration or tremor. Normally, the pulse is stronger 
upon inspiration ; but it may be weaker, constituting tlie 
pulsus joaradoxus. A regular arrhythmia is known as allor- 
rhythmia. 

Etiology: Arrhythmia may be caused directly by lesions in 
the brain and spinal cord aifecting the centres of tlie pneumo- 
gastric and accelerator nerves. Among such lesions are men- 
ingitis, apoplexy, tumors, and abscess. The nerves may be 
jyressed upon by enlarged glands in the neck, including the 
thyroid and thymus glands, or by tumors or aneurism. Aneur- 
ism of the arch of the aorta may produce arrhythmia. 
Arrhythmia may also occur in pericarditis, myocarditis, endo- 
carditis, arteriosclerosis, ancemia, chlorosis, leul'ocythcemia, or 
in cases of distention of the stomach or intestines ivith gas, or 
upward displacement of the diaphragm by fluid. Just before 
death the heart may become irregular as well as weak. The 
most common reflex causes are injuries of the abdominal 
organs, kidneys, or uterus, and severe pain. Among the 
toxic causes are the infectious diseases, especially typhus fever, 
scarlet fever, cerebro-spinal meningitis, diphtheria ; Bright's 
disease and rheumatism ; the abuse of alcohol, tobacco, coffee, 

21— p. M. 



322 DISEASES OE THE ORGANS OF CIRCULATION. 



and tea. Arrhythmia may be caused by emotions, especially 
home-sickness, love-sickness, and domestic infelicities. 

In diagnosis the most important item is the discovery of 
the cause, the recognition of which takes the arrhythmia out 
of the category of diseases of obscure or unknown causes and 
makes it a symptom. 

The prognosis and treatment depend upon the cause. 

PALPITATION. 

Palpitation is a beating of the heart that is felt by the 
patient. 

Etiology : The direct causes are organic diseases of the heart, 
especially those due to arterio-sclerosis or Bright\s disease ; 
irritations in the brain and spinal cord, including the emotions 
and organic diseases of the central nervous system, especially 
tabes dorsalis, disseminated sclerosis, progressive paralysis, 
epilepsy, Basedow^s disease, neurasthenia and hysteria ; irri- 
tation of the nerves supplying the heart, caused most frequently 
in the neck by tuberculous glands. The reflex causes are 
located chiefly in the abdomen and pelvis. Thus palpitation 
may be caused by affection of the stomach, distention of the 
stomach or intestines with gas, constipation, prostatitis, sal- 
pingitis, sexual excesses and perversions, puberty, and severe 
pain. The more common toxic causes are the abuse of alco- 
hol, tobacco, coffee and tea, Briglit's disease, gout, ansemia, 
leukocythsemia, chlorosis, scurvy, and plethora. 

The diagnosis concerns chiefly the discovery of the cause, 
upon \yhich the prognosis and d-catment largely depend. 

Treatment : During the attack the individual should ob- 
serve absolute rest, best in bed. The cause of emotions, 
especially anxiety, should be removed if possible. Excessive 
action of the lieart may be quieted by cold applications, best 
in the form of the ice-bag or cold compresses, placed over the 
heart. Mild cases are relieved by the use of the sodium 
benzoate of caffeine, gr. iij-v, or sodium bromide, gr. xx-xl 
largely dihited, or valerian or ergotin. In bad cases the 
attack may be cut short by the administration of brandy, 
Hoffmann's anodyne, the compound spirit of ether, or the 



TACHYCARDIA. 



323 



aromatic spirit of ammonia, or by morphine subcutaneously. 
In all cases the cause of the palpitation should be sought and 
remov^ed or properly treated. 

TACHYCARDIA. 

Tachycardia is an increased rapidity of the action of the 
heart to more than 100, sometimes reaching 200 or even 300 
beats per minute. Increased frequency of the beating of the 
heart may be due to Basedow\s disease, some change in the 
nerve-centres, or continuous toxic irritation, and occurs some- 
times in the absence of demonstrable disease. Tachycardia may 
be periodic or transitory in cases of fever, especially the infec- 
tions, in convalescence and in degradation of the blood, anae- 
mia, etc. Attacks of paroxysmal tachycardia may be due to 
the accumulation of toxins, the symptoms disappearing upon 
the elimination of the toxins. 

Tachycardia — etiology: Among the direct can-e-, acting 
chiefly upon the pneumogastric nerve, are the ( mot i'jii--<, which 
interfere with the inhibitory action of the cerebrum ; orr/anio 
affections of the brain, meningitis, sclerosis, tumors, softening ; 
tumors in the neck, enlarged glands; and iiiffnuiinr/fions and 
degeneration of the heart-muscle. Rarely tachycardia may 
occur reflexly from disease in other organs. The more com- 
mon toxic causes are Bright's disease, tuberculosis, rheuma- 
tism, and occasionally gout and lead-poisoning. Sometimes 
the cause of tachycardia may not be found. Such cases are 
ascribed to toxins of cryptogenetic origin, or to molecular 
changes in the nerve-centres similar to those which are sup- 
posed to exist in epilepsy and migraine. 

The prognosis as to life is good, so far as the tachycardia is 
concerned ; but death may be due to the cause of the tachy- 
cardia. Cases usually prove obstinate to treatment. 

Treatment : The attack may be relieved in some cases by 
compression of the vagus in the neck. Sometimes attacks 
may be aborted by the use of morphine and atropine, nitro- 
glycerin, or inhalations of amyl nitrite. In addition to the 
treatment of the attack, effort should be made to discover and 
remove the cause. 



324 DISEASES OF THE OBGANS OF CIRCULATION. 



BRADYCARDIA. 

Bradycardia is a reduction of the pulsation of the heart to 
40 or less beats per minute. 

Etiology : Permanent bradycardia may be caused by irrita- 
tion of the pneumogastriG nerve, which may occur in pachy- 
meningitis, cerebro-spinal meningitis, trauma, hydrocephalus, 
tumors, and abscesses. Bradycardia and epilepsy often co- 
exist, when both are usually due to the same cause. Tern- 
porary bradycardia occurs in the infections, especially typhoid 
fever, diphtheria, pneumonia, erysipelas, and rheumatism ; in 
puerperal fever, jaundice ; and in cases of absorption of 
toxins, as from the intestinal canal in cases of occlusion. 
Paroxysmal tachycardia is usually attributed to nervous 
causes. Among the direct causes of bradycardia are all those 
conditions, including disease or injury of the brain, which may 
cause irritation of the vagus nerve. Reflex bradycardia arises 
chiefly from some abdominal irritation. Toxic cases are due 
to uraemia, icterus, and the toxins. Chronic cases are frequently 
due to lead-poisonino^ or gout. 

The prognosis should be guarded, and depends largely upon 
the cause. 

Treatment : If possible, the cause should be found and re- 
moved or properly treated. Heart-stimulants are indicated 
only in the presence of a failing heart. 

ANGINA PECTORIS. 

Angina pectoris is marked by excruciating pain in the region 
of the heart, radiating to the left shoulder and arm. 

Etiology : The pain of angina pectoris is the cry of the tis- 
sues for fresh blood. The blood-supply of the heart is par- 
tially or completely cut off by sclerosis involving +he coronary 
arteries or by an atheromatous plate in the aorta at the origin 
of the coronary arteries. 

Symptomatology : The disease develops slowly, as an arterio- 
sclerosis or atheroma, but the attack comes on suddenly and 
with great severity. There are no premonitory symptoms. 
The individual is literally transfixed with pain in the region of 



PSEUDO-AXGIXA. 



325 



the heart and radiating to the left shoulder and arm. There is 
extreme anxiety. The attack may last from a fraction of a 
minute to several hours ; as a rale, hwt a few minutes, and 
usually terminates abruptly. 

Diagnosis : The extreme pain in the region of the heart and 
the anxiety during the attack are characteristic. There may 
be found some evidence of arterio-sclerosis or disease of the 
heart, myocarditis or valvular disease, especially stenosis of 
the aortic valves. The patient is usually past middle life or 
is an individual in whom the changes of age have been pre- 
cipitated. 

The prognosis is grave ; but even bad cases may recover. 

Angina pectoris — treatment : During the attack the indi- 
vidual instinctively observes absolute rest. Further relief of 
the arterial tension may be secured by the use of amyl nitrite 
by inhalation, gtt. ij-v, which should be discontinued with 
the cessation of the attack. Suitable doses of the amyl nitrite 
may be carried by the patient in the form of the so-called 
pearls," which are broken and inhaled from a handkerchief. 
Persistent attacks may call for the use of the ana?sthetics, 
preferably ether. Nitroglycerin niay be given to prevent 
attacks, but acts too slowly for satisfactory use during attacks. 
Sodium nitrite and potassium nitrite are sometimes used. Pro- 
tracted cases may demand the use of morphine. 

PSEUDO-ANGINA. 

Pseudo-angina usually occurs before the meridian of life, 
most frequently in subjects of hysteria or neura>thenia. 

Etiology : Among the direct causes are affection of the 
branches of the pneumogastric nerve supplying the heart, and 
the cerebral changes which find expression in hysteria and 
neurasthenia. Emotional excitement plays a prominent role. 
Some cases may be traced to a reflex or toxic cause. The re- 
semblance of the location of the pain in some cases to the dis- 
tribution of herpes zoster has led ^Mackenzie to locate the 
cause in an infection affecting the posterior roots of the spinal 
nerves, especially the ganglia. The reflex causes are found 
chiefly in the alimentary canal, marked by associated dys- 



326 DISEASES OF THE ORGANS OF CIRCULATION. 



pepsia or indigestion ; frequently in the uterus and ovaries, 
with djsmenorrhoea, salpingitis, etc. Among the toxic causes 
are alcohol, tobacco, coffee, tea, gout, and lead-poisoning. 

Symptomatology: Pseudo angina differs from true angina 
chiefly in the i^redominaiice of emotional symptoms and symptom s 
on the part of the vaso-motor system — vaso-motor angina. 

Diagnosis : The emotions, the age and sex of the patient, and 
the existence of other evidence of hysteria or neurasthenia 
suffice to make the diagnosis. 

Prognosis : Good. 

Treatment : The treatment should be directed especially to 
the underlying cause. The attacks may be relieved by the 
administration of valerian, the bromides, Hoffmann's anodyne, 
sometimes by hot or cold applications or the use of a mustard- 
plaster. 

DISEASES OF THE BLOODVESSELS. 

ACUTE ARTERITIS. 

The arteries may suffer acute inflammation, the process be- 
ginning in the vaso-vasorum. Such inflammation is seen most 
frequently in the acute infections, especially typhoid fever, 
pneumonia, and influenza ; less frequently in smallpox, scarlet 
fever, and diphtheria. The inflammation may cause occlusion 
of the vessel, which may be followed by necrosis or gangrene ; 
or the inflamed artery may become a depot of infection, giving 
rise to disseminated metastases and septicaemia. 

ACUTE AORTITIS. 

Inflammation of the wall of the aorta is accompanied by 
dyspnoea, marked by long, painful inspiration and short ex- 
piration. The discomfort varies in intensity from a feeling 
of constriction in the throat to intense pain, that may even 
resemble the agony of angina pectoris. The ascending aorta 
becomes dilated and elongated, so that the heart is displaced to 
the left, and the arch of the aorta sometimes becomes promi- 
nent in the neck, and the subclavian arteries may be detected 
by palpation above the clavicles. 



AB TEEIO-SCZ EE OSES. 



327 



The treatment is rest, with the relief of pain bv opium when 
neces-arv. and the rtlit-i' of the dyspncea by the inhalation of 
aniyl nitrite ur cihyl iijJiiie. 

AETEEIO-SCLEROSIS. 

Arterio- sclerosis is a degenerati*jn of the walh of the arteries, 
frequently associated with atheromatous, caleareou-, or fatty 
changes. The strtictural elements of the vessel-wall are sub- 
stituted by connective tissue. 

Etiology : The more important causes of arterio-sclerosis 
are alcohol, syphilis, rheumatism, and gout. Most cases are 
found in the aged. The disease is more commnn in the two 
extremes of society — the rich and the poor. Both hard Avork 
and high living are prominent causes. Arterio-sclerosis al-o 
occurs frequently in lead-poisoning, diabetes, and after the 
infections, especially typhoid fever, malaria, influenza, scarlet 
fever, and diphtheria. Other causes of arteriu-scleru?is are 
bad habits and depressing emotions, especially v. orry. 

Symptomatology : Arterio-sclerosis may exi-t even in marked 
degree and show no symptoms. One of the most prominent 
early symptoms is increase in the hlood-pressure, which may 
be recognized at the pulse by the hnoer : or in finer degrees 
and more accurately by means of the sphygmograph and 
annr" ■ i\ Sometimes the vessels mail be felt as hard cords, 
reseCi .1..^ -late-pencils. 

In general arterio-sclerosis, as in aHe'rio-ca-pillary fibrosis, 
the hJood-pressii/re is increased and the heart becom^'S h yper- 
trophied. The cardiac impulse is greater, the apex of the heart 
displaced : the aodic valve sound, Avliieh is the -eeend sotmd 
at the base of the heart to the right of the sternum, is accen- 
tuated, and the diameters of the heart are increased, especiolly 
to the left. Later the hypertrophy gives way to dilatation, 
with a loss of all the signs except the evidence of an increased 
size of the heart. Elongxttion of tlie aorta may permit a change 
of position of the a:pe:c-b>:a.t. Thu-. an apex-beat which is 
found in the normal position with the ]iatient in the upright 
posture mav be chano-ed as far to the left as the axillary line 
when the individual lies upon tii"- left side. 



328 DISEASES OF THE ORGANS OF CIRCULATION. 



Atheroma of the aorta may diminish tlie supply of blood 
to the body. There may be present a) tear ism of the aorta. 
Atheroma at the orifice of the coronary arteries may give rise 
to arrhythmia, heart-failure, or angina pectoris. 

Atheroma of the aorta is frequently associated with ather- 
omatous changes in the aortic valves. 

Sclerosis of the coronary arteries causes palpitation, especi- 
ally after meals, and dyspnoea upon even light exercise. In 
some cases physical elfbrt is followed by pain under the 
sternum, radiating to the left arm. 

When the process involves the brachial and intercostal 
arteries, the blood-supply to the respiratory muscles is lessened, 
and there result ossification of the costal cartilages and pul- 
monary emphysema. 

Sclerosis of the puhnonary artery occurs especially in cases 
of chronic stasis of the lung, as in mitral stenosis and tuber- 
culosis. There are paroxysmal dyspnoea, palpitation, vertigo, 
and cyanosis, with hypertrophy of the heart, especially the 
right ventricle. 

Arterio-sclerosis in the kidneys causes a granular atrophy, 
which begins as a degeneration in the small arteries. 

Arterio-sclerosis is manifested on the part of the brain by 
alteration of disposition and mental disturbances. The in- 
dividual becomes irritable and dejected. Mental strain causes 
exhaustion sooner than formerly. The mental faculties l)e- 
come weakened ; there are impairment of motion, vertigo, in- 
somnia, sometimes transitory aphasia, delirium, delusions ; and 
at last the evidences of softening of the brain. Hemiplegia 
and apoplexy may occur at any time. Affection of the small 
vessels is usually present in chronic myelitis, tabes, multiple scle- 
roses, syringomyelia, progressive paresis, and senile dementia. 

Arterio-sclerosis of tlie vessels of the extremities mny cause a 
lowering of the surface- temperature of the part supplied by 
the affected vessels, with cyanosis and gangrene. The hard 
arteries may be palpable. 

Diagnosis : Tlie most im})ortant symptoms in diagnosis are 
the evidences of hypertrophy of the right ventricle and in- 
creased blood-pressure, in the absence of any other discover- 
able cause, such as valvular disease, Bright's disease, etc. 



ANEURISM. 



329 



Affection of the superficial arteries may be detected by pal- 
pation. There may be the evidence or history of some 
etiological factor, such as syphilis, alcoholism, hard work, 
saturnism, gout, etc. Usually the earliest sign is increased 
blood-pressure. Later there is dyspnoea upon slight effort, pal- 
pitation, precordial anxiety, coldness of the extremities, sen- 
sations of numbness, crises of pallor, and violent headache. 
There is early accentuation of the aortic valve sound, hyper- 
trophy of the heart, and later dilatation. 

Atheroma of the coronary arteries causes deficient nutrition 
of the body, with consequent marasmus, through a failing of 
the action of the heart. On the part of the heart there may 
be angina pectoris. 

Chronic aortitis shows dyspnoea upon slight effort, which 
may not be accounted for by disease of the heart. In addi- 
tion there may be the symptoms of arterio-sclerosis in other 
parts of the body, or the evidence or history of some cause 
of arterio-sclerosis. 

The arcus senilis is an expression of arterio-sclerosis. 

The Rontgen ray may reveal the deposits of arterio-sclerosis. 

The prognosis is grave. Much depends upon the location 
and degree of the sclerotic changes, and the ability of the 
individual to regulate his life. 

Prophylaxis demands moderation in eating, drinking, and 
exercise, the avoidance of bad habits, and the proper treat- 
ment of obesity, diabetes, lead-])oisoning, and gout. 

Artsrio-sclerosis — treatment : The individual should live a 
life temperate in all things. If possible, the cause of the 
arterio-sclerosis must be discovered and removed. Of drugs, 
the iodides are the most valuable. Potassium iodide or sodium 
iodide, which is less depressing, or probably better the tincture 
of iodine, gtt. x in a wineglassful of sweetened water, may be 
given before meals. Systematic, carefully graded exercise, 
best out of doors, is of considerable value. Further treat- 
ment is symptomatic. 

ANEUB.ISM. 

Aneurism, a circumscribed dilatation of an artery, occurs 
most frequently in the external arteries. In order of fre- 



330 DISEASES OF THE ORGANS OF CIRCULATION. 



quency, aneurism occurs in the popliteal, crural, carotid, and 
the axillary arteries. 

Internal aneurism occurs, in the order of decreasing fre- 
quency, in the aorta, subclavian, innominate, and pulmonary 
arteries. The cerebral arteries are atlected as follows, in the 
order of frequency : the middle cerebral, basilar, internal 
carotid, anterior cervical, posterior communicating and anterior 

communicating, tlie vertebral, pos- 
terior vertebral, and the inferior 
cerebellar. 

Dissecting aneurisms are due to 
rupture of the internal and middle 
coats of the artery, the blood mak- 
ing a channel l)etween the middle 
and outer coats, or between the 
laminae of the middle coat. 

Miliary aneurisms, usually con- 
sisting of a large number of small 
dilatations, are found especially in 
the brain. 

Etiology : The chief causes of 
aneurism are syphilis, alcohol, 
gout, rheumatism, strain, and de- 
^. ,. . pressino^ mental emotions. 

Dissectmp: JincMTrism on a eere- i 

bral vessel, simulating miliary Symptomatology : I lie dlSCaSC 

aneurisms (Schmaus). • i j i /> i 

may remain latent lor a long time. 
Twenty per cent, of cases show no symptoms. 

The cliief symptoms of aneurism of the aorta are pain, 
parwsthesioe, paresis, dyspnoea, cyanosis, hoarseness, dysphagia, 
palpitation, the presence of a pulsating tumor, and pressure- 
symptoms. 

The tumor may cause various symptoms by pressure upon 
the oesophagus, branches of the vagus nerve, the intercostal 
nerves, branches of the brachial plexus, the spinal cord (after 
erosion of the vertebrae), the intestines, liver, bile-ducts, kid- 
neys, and ureters. The apex-heat is displaced to the left and 
downward when the patient lies upon the left side. The left 
radial and carotid pulse is feeble or retarded. 

Physical examination reveals a thrill or bruit. Rarely the 




THROMBOSIS. 



331 



bruit may be heard only upon placing the bell of the stetho- 
scope in the patient's mouth. 

In aneurism of the abdominal aorta the pain is usually more 
ditiluse. The chief pressure-symptoms are stenosis or obstruc- 
tion of the intestine, biliary or renal colic, ascites, jjJOMi (gas- 
tralgia, enteralgia), parsesthesise, paresis, and paralysis. The 
jyulxc is retarded in the crural arteries. A pulsating tumor is 
found in tlie abdomen ; but not every pulsating tumor in the 
abdomen is an aneurism. 

Aneurism of the pulmonary artery usually occurs in con- 
nection with arterio-sclerosis and mitral stenosis. 

Hiipture of an aneurism is followed by immediate col- 
lapse. 

The diagnosis depends upon the pressure-symptoms, pain, 
palpitation and dyspnoea, dislocation of the apex-beat, the de- 
tection of a pulsating tumor, and the characteristic thrill or 
bruit. Aneurism differs from tumors in causing more rapid 
erosion of bone than of the soft structures. The discovery 
of an etiological factor is often a valuable point. Doubtful 
cases may call for aspiration with a fine needle. 

The prognosis is grave, but not necessarily fatal. The 
aneurism may lead to a fatal termination through rupture; or 
the sac may become obliterated and the individual recover. 

Treatment : The blood-pressure should be lowered by abso- 
lute rest and a light diet. Medicinal treatment consists 
largely in the use of iodine, in the form of the tincture or 
the potassium or sodium salt. Further treatment is symp- 
tomatic or surgical. Quiescent cases should be let alone ; 
cases that are progressing unfavorably may be relieved by 
surgery. 

THROMBOSIS. 

Definition : More or less complete occlusion of a vessel by 
a blood-clot. The process may occur in any part of the vas- 
cular system, most frequently in the arteries and veins. 

Etiology : Thrombosis depends upon stasis of the blood and 
injury to the vessel-wall or blood by toxins or micro-organ- 
isms. The process occurs most frequently in the infections- — 
septicaemia, tuberculosis, carcinoma, and Bright's disease. 



332 DISEASES OF THE ORGANS OF CIRCULATION. 



The symptoms depend upon the location and character of 
the thrombus. 

The diagnosis is made by the existence of an infection and 
the evidence of the cutting off of the blood-supply to a part 
of the body, and, in the case of septic embolism, by the occur- 
rence of a depot of infection at the point of embolism with 
the usual symptoms of sepsis. 

The prognosis depends upon the character and cause of the 
thrombus, its location, and the general condition of the patient. 

Treatment demands rest and address to the cause. Other- 
wise the treatment is symptomatic. 

EMBOLISM. 

Definition : Interference with the circulation, caused by the 
arrest of an embolus or particle of foreign material in the 
circulation. 

The symptoms of embolism vary with the character of the 
embolus and the location of the embolism. The embolus may 
be composed of fat, air, particles of a thrombus, etc. The 
chief sites of embolism are the brain, lungs, coronary arteries, 
splenic artery, mesenteric arteries, the kidneys, tympanum, 
and retina. There is interference, more or less marked, with 
the function of the organ affected. 

Embolism of the brain occurs most frequently in the branches 
of the left carotid. Embolism of a large branch causes apo- 
plexy, abolition of consciousness, coma, and hemiplegia. Sep- 
tic emboli cause abscess, usually with meningitis. 

Embolism of the lungs is announced by severe pain, sympa- 
thetic vomiting, and dyspnoea ; sometimes with cyanosis, con- 
vulsions, and syncope (see Infarction of the Lung). 

Embolism of the liver : Chill, fever, and icterus, with pain, 
swelling, and tenderness in the region of the liver. 

Embolism of the spleen : Chill, fever, and severe pain in the 
spleen, which is enlarged and tender. 

Embolism of the kidneys : Chill, fever, vomiting, and pain 
in the kidneys, with albuminuria and hsematuria. 

Embolism of the mesenteric arteries : Abdominal pain, diar- 
rhoea, and the appearance of blood in the faeces. 



PHLEBITIS. 



333 



Embolism of the retina : Sudden blindness. An infarction 
may be recognized upon ophthalmoscopic examination. A 
septic embolus may cause panophthalmitis with destruction 
of the entire globe. In such cases the affection of one eje is 
usually followed by affection of the other eye. 

Embolism of the skin : Eruptions of various sorts appear — 
roseola, urticaria, petechia, ecchymosis — sometimes resembling 
the eruption of measles, scarlet fever, variola (pustules), or 
pemphigus (bullae). In some cases there are sweating and 
sometimes desquamation. The vskin of the lower extremities 
is most frequently affected, although the skin over the entire 
body may suffer from embolism. 

Differential diagnosis : Embolism differs from thrombosis, 
as a rule, in being of more sudden onset. Embolism occurs 
especially in heart-disease, thrombosis in arterio-sclerosis. 
Embolism is further distinguished by affection of various or- 
gans. Embolism of the brain is difierentiated from cerebral 
hemorrhage by the more sudden onset without prodromata, 
preference for early life and the female sex, and the connec- 
tion with valvular disease. 

The treatment of embolism demands rest and address to 
the cause. Further treatment is symptomatic. 

PHLEBITIS. 
Definition : Inflammation of the veins. 

The symptoms vary with the vein affected and the charac- 
ter of the inflammation. Femoral phlebitis gives the symp- 
toms of a thrombosis — arrest of circulation, and cedema of the 
leg, constituting the condition known as phlegmasia alba 
dolens. Such a phlebitis occurs most frequently in the puer- 
perium. Umbilical p)hlehitis usually causes pain, fever, ano- 
rexia, hemorrhage, and collapse. Severe cases may show 
icterus. Pijophlebitis is a purulent inflammation caused by 
infection of a vein (e. g., the portal), marked by the usual 
symptoms of septicaemia : chills, sweats, rapid weak pulse, 
clouded sensorium, diarrhoea, and collapse. There may be 
pain, icterus, ascites, dilatation of superficial veins, hemor- 
rhoids, and hemorrhage from the bowels. Abscess may be 
differentiated by aspiration. 



334 DISEASES OF THE OEGANS OF CIRCULATION. 



The treatment, further than rest and address to the cause, 
is symptomatic. 

VARICES. 

Varices, or phlebectasise, are more or less circumscribed dila- 
tations of the veins, some^vhat analogous to aneurisms in 
arteries. The veins become elongated and tortuous. Varices 
occur most frequently in the loAver extremities, pelvis (broad 
ligaments), spermatic cord, prostate gland," and loM er part of 
the rectum (hemorrhoids). A familiar example is the caput 
Medusae, caused by cirrhosis of the liver and pyophlebitis. 

Etiology : The chief causes are gravity, constriction of 
veins, age, syphilis, strain, alcohol, tobacco, lead-poisoning, 
and gout. 

The symptomatology varies with the location and extent of 
the affection. There may be parsesthesia, neuralgia, altera- 
tions of the secretions, proctitis, venous stasis, elephantiasis, 
and various kinds of eruptions and ulcers. 

Treatment calls for rest and gentle compression. An 
affected member should be elevated. Compression may be 
secured, in affection of the lower extremity, by the elastic 
stocking, and by the use of the suspensory bandage in affec- 
tion of the spermatic cord. Further treatment is surgical. 

DISEASES OF THE MEDIASTINUM. 

The more important diseases of the mediastinum are medi- 
astinitis or inflammation of the mediastinum ; abscess of the 
mediastinum and mediastinal neoplasms. The principal neo- 
plasms found in the mediastinum are sarcomata, carcinomata, 
dermoid and hydatid cysts. The mediastinum may also be 
the seat of syphilitic or tubercular growths. 



CHAPTEE V, 



DISEASES OF THE BLOOD. 

Ix this division v.-ill l.^ rT,n-i''l>rred the diseases character- 
ized by L'haii2'es in ' - ^ -'-'Ai are believed to be due 
to diseases uf the bi'„-j'.i : '^r iji ' 'r_ans having some intimate 
connecti':>n with the bL.Mjd. 

Tn^ fArrrfsri,: r/;.v/, . . - l,i,),:Hl hnv.: r-r./eived considera- 

lii^n under Di-t'inii:;-.-, . . O-i-. AI^iOuO:. 

The no/-: . ' ■ : = in :ii:lult is 

4, ,M:n;; ■ ^ lu- niiuii:, ^. . ' ^ ' J ' J - ^ . ' , " J ' _ ' . ' J J U per 

■ : : ■ , I numl^^^r '"'t O'-rpu-'df s inorea-es wiih 

rnt- ai:iru'.ie. Tnu-. L:\\^.^\i-' j'-^\vi-\ -az Ohri-tiana. at the sea- 
level. 4.970.'">0(» con--;-.-;— pvr •.•u:.-:-^ rnillirnetre : Yiault. at 
(Jordni -r:-, 4^"'i: r'-et above sea-level. I'-^nid ^.m'r^j'j ■C^ 

Tjif !'A'''r "1 the various hiruJ^ 'A 1':a.:'j'j .'^'s. in adults 

and infant-. ac--'jrding to the investigation of ^Shattuck and 
Cabot, are as follows : 

Adults. Infants. 
P " " / " nuclear nentropliiles . 60 -70 per cent. 25-40 per cent. 

L;.-0; i; _ ... 13 -30 40-60 

L:;: .:r jniiclear andtraniidonal 4 - S " 6-12 *' 

Eo,duophile5 0.5- 4 1-10 " 

PLETHOEA. 

The red iDlood-corpuscles -h' lw a cornp<:' ■/'^'^'•^■^^ when 

the blood becomes more djucentrated thr- loss of its 

watery element-. Such a comparative incrfa-e of the cor- 
iv ■!=•:•"! -■■-'■-n in --v-r-:- -f diarrhcea. chnlera. and in 

' _ -'v ^rin^^ etc. A -imilar C'^an- 

parative increa-- ■ - i [ - ■ V;-- • • ; ] : : v be 

produced bv ex-r . ::i;>-:i_' . <'V v. ;i:-.n wni'jii '-a;:-- in- 
^^rea^ed bh''"'d-prp^^ir:-_^ and f^rce the serum out of the vessels. 

An nbsolute iucrccfst of the red blood-corpuscles is found in 



336 



DISEASES OF THE BLOOD. 



the new-born, or may be caused by residence in high altitudes, 
delayed menstruation, cyanosis, myxcedema, and phosphorus- 
poisoning. The number of corpuscles per cubic millimetre 
may be increased by increased blood-pressure. True plethora 
should not be confounded with the ''plethoric habit due to 
vaso-motor disturbance or venous stasis. 

ANAEMIA. 

Anaemia may be roughly divided into jjrimary anaemia, in 
which the chief etiological factor is believed to be in the blood 
or some organ in intimate connection with the blood ; and 
seemidary ansemia, in which the cause is probably not in the 
blood or in the so-called blood-making organs. 

Primary ancemia includes chlorosis and pernicious anaemia. 

Secondary ancemia includes the anaemias caused by hemor- 
rhage, poisoning, the infectious diseases, malignant diseases, 
and the anaemias found in the insane. 

CHLOROSIS. 

Definition : An anaemia sometimes marked by a yellowish- 
green tint, occurring most frequently in girls about the time 
of puberty, seventeen to twenty-three years of age. 

Etiology: The chief factors in causation are the infectious 
diseases, especially tuberculosis ; constipation and the absorp- 
tion of ptomaines, and bad hygiene. Many cases are ascribed 
to ''cold,'' change of climate, and emotional disturbance or 
bad habits. The disease is believed to bear a relation to the 
establishment of ovulation. Often heredity seems to play a 
role. 

Chlorosis — symptoms : The patient comes to feel tired and 
sleepy all the time and loses interest in life; there are headache, 
palpitation, anorexia, sometimes nausea and vomiting, fre- 
quently perverted appetite, constipation, and dysmenorrhoea or 
amenorrhoea. The tongue is coated, the breath foul. The shin 
and mucous membranes are pale, with a yelloivish, greenish, or 
bluish tint. The blood, is paler and more fluid than normal ; 
there may be a slight diminution in the number of the red 



PERNICIO US A NuEMIA . 



337 



blood-cells ; usually the number of white blood-cells remains 
about normal ; the number of blood-plates is increased. The 
most marked change in the blood is the great reduction in 
hcenioglobin. Usually there is a soft si/stoUc mui-nii'r^ heard 
most distinctly over the pulmonary valves. The second pul- 
monary sound is accentuated. The bruit de diable may be 
heard over the bulb of the jugular vein. There is increased 
frerpiency of respiration, even in the absence of exercise, as 
in rest and sleep. Thrombosis may occur, most frequently in 
the femoral vein. The plugging of a cerebral sinus may cause 
death. 

The diagnosis is easy in the presence of typical changes in 
the blood. Before such changes occur the diagnosis is diffi- 
cult. In all cases an attempt should be made to rule out per- 
nicious anaemia and the secondary anaemias. 

The prognosis is usually favorable. 

Chlorosis — treatment : Bad cases should be confined to bed. 
Persistent cases may require a change of climate. Usually 
the disease responds readily to iron. A good form of iron is 
the improved Blaud pill. Arsenic may also be given, prob- 
ably best as Fowler's solution or Roncegno water. Constipa- 
tion is relieved by cascara or the pill of aloes and iron. Symp- 
toms on the part of the stomach may be met with lavage and 
the administration of dilute hydrochloric acid, gtt. x-xx in a 
wineglassful of water before meals. Sometimes it is advan- 
tageous to use some bitters, the infusion of condurango, 
calumbo, absinthe, or the aromatic tincture of rhubarb. Bad 
habits and bad hygiene should be corrected. Nux vomica or 
gentian with bicarbonate of sodium often give good results. 

PERNICIOUS ANEMIA. 

The etiology is obscure. Upon the discovery of a cause, 
most observers no longer classify cases as pernicious anemia. 
Thus, many cases, which formerly would have been classified 
as pernicious anaemia, are now known to be infections by 
animal or vegetable parasites — e. g., helminthiasis, malaria, 
tuberculosis, syphilis, etc. 

Pernicious anaemia is most frequent in middle life, thirty 
22 —p. M, 



338 



DISEASES OF THE BLOOD. 



to sixty years, although cases have been reported in infancy 
and old age. 

Pernicious anaemia — symptomatology : The disease conies on 
gradually with pallor, sometimes with a light icterus. The 
patient complains of weakness and dyspnoea. (Edema appears 
first about the ankles and eyelids; later there is effusion into 
the serous cavities. Notwithstanding the anaemia and degra- 
dation in strength, the nutrition of tHe body suffers no or only 
slight impairment. There may even be some fat apparent. 
Emaciation is the exception. As a rule, there is more or less 
irregular continuous fever. There is usually anorexia and an 
offensive breath, and frequently there are periods of nausea 
and vomiting. Occasionally patients complain of a voracious 
appetite. There may be constipation or diarrhoea. Physical 
examination may show enlargement of the liver and spleen. 
The most frequent symptom on the part of the nervous sys- 
tem is headache ; thei'e may be neuralgias, parsesthesise, pareses, 
apoplectiform attacks and delirium, numbness, tingling, lanci- 
nating pains, spasms, and delusions and hallucinations of sight 
and hearing. Hemorrhage occurs often, especially from the 
nose and gums. Retinal hemorrhage is not infrequent. Palpi- 
tation, vertigo, and faintness are common. Systolic ancemic 
murmurs may be heard over the base of the heart. Some 
cases show the Corrigan pulse. Examination of the chest 
may reveal the moist rales of passive congestion, and some- 
times the presence of hydrothorax. 

j\Iost important are the symptoms on the part of the blood. 
The blood is pale and thin. The number of red blood-cor- 
puscles varies from 1,000,000 to 500,000 or less per cubic 
millimetre. The reduction of red blood-corpuscles does not 
bear a direct ratio to the apparent health of the individual. 
The haemoglobin usually shows a relative increase. The num- 
ber of wdiite blood-corpuscles may be increased or diminished. 
The blood-plates are decreased in number. Poihilocytosis fre- 
quently occurs, but is not pathognomonic of pernicious anaemia. 
Niimmulcdion is imperfect or absent. The red blood-corpuscles 
are increased in size. Shattuck and Cabot, found a red blood- 
corpuscle measuring 17 by 19.6 fj.. The normal is about 
7.5 (JL. The nucleated red blood-corpuscles are characteristic 



THE SECOXDARY AX^MIAS. 



339 



in the predominance of megalohlasts, and atypical corpuscles, 
and the diminution of normoblasts. The number of nucleated 
red blood-corpuscles may vary Avidely in the same case from 
time to time. FolychromatophUic^ nucleated red blood-cor- 
puscles, the protoplasm of which shows an affinity for 
Ehrlich's tri-color mixture, are found in pernicious ansemia 
more frequently than in other anaemias. 

The leukocytes are diminished in number, but there is a 
relative increase in the number of the small mononuclear 
leukocytes. There is a small number of myelocytes, which 
occur in large numbers in splenic myelogenous leukaemia, and 
are occasionally found in chlorosis and the secondary anaemias. 

The diagnosis is made by an examination of the blood. 
Secondary anaemias should be excluded. Every effort should 
be made to find the cause. 

The prognosis is grave, but not necessarily fatal. The dura- 
tion of life is usually about one or two years, rarely three or 
four years. Hope lies largely in the discovery of the cause, 
Avhen the case becomes one of secondary anaemia rather than 
of pernicious anaemia. 

Pernicious anaemia — treatment is largely symptomatic. Fow- 
ler's solution of arsenic, beginning with gtt. ij doses and in- 
creasing to tolerance, deserves a trial. 

THE SECONDARY ANuSlMIAS. 

Secondary anaemia is found especially in cases of gastric 
ulcer, menorrhagia and metrorrhagia, hemorrhoids, haemophilia, 
and traumatism ; poisoning by lead and arsenic ; malaria, 
syphilis, tuberculosis, leprosy, typhoid fever, septicaemia, 
Bright's disease, cirrhosis of the liver, and malignant disease. 

Symptomatology: The individual is pale and suffers from 
muscular weakness, dyspnoea, vertigo, syncope, anorexia, vom- 
iting, and emaciation. 

The diagnosis has to do chiefly with the discovery of the 
cause, upon which the prognosis depends. 

The treatment, aside from address to the cause, consists 
largely in the administration of iron and arsenic, and an 
abundance of nutritious food. Persistent cases may be bene- 
fited by a change of residence to a higher altitude. 



340 



DISEASES OF THE BLOOD. 



LEUKOCYTOSIS. 

In leukocytosis there is an increase in the number of leuko- 
cytes in the peripheral blood. The average number of white 
blood-corpuscles to the cubic millimetre of blood varies nor- 
mally from 5000 to 10,000 ; in leukocytosis the number may 
reach 70,000 or more. The proportion of white to red t)lood- 
corpuscles, which normally varies from 1 : 400 to 1 : 1000, may 
reach in leukocytosis 1 : 50, or even 1 : 5 (Litten) in the death 
agony. 

Leukocytosis occurs normally, or physiologically, in the 
new-born ; after the digestion of proteids ; during increased 
blood-pressure after exercise, massage, electricity and cold 
baths ; especially during the later months of pregnancy ; 
during the puerperium, gradually decreasing after the first 
day ; and in the moribund state, and just before death. 

Leukocytosis occurs abnormally, or pathologically, after 
hemorrhage, corresponding in degree with the ansemia pro- 
duced ratlier than with the amount of blood lost ; and in the 
infectious diseases. Perhaps the most marked leukocytosis 
has been found in the huhoniG plague, in which 200,000 has 
been observed (Aoyoma). 

Leukocytosis occurs in some cases of diabetes ; in the so- 
called uric-acid diathesis ; in cases of poisoning by illuminat- 
ing-gas ; after injections of ergotin and tuberculin or of the 
normal saline solution ; during and after ether-narcosis ; after 
the internal use of the salicylates; and in cases of malignant 
disease, especially when of rapid grow^th. Malignant disease 
may interfere with the ingestion of food, and thereby cause 
a decrease in the number of leukocytes. 

The following diseases are marked by an absence of leukocy- 
tosis : Pure infections by the typhoid bacillus or tubercle 
bacillus, although typhoid fever and tuberculosis frequently 
show leukocytosis, due to the secondary septicaemia in tliese 
diseases ; malaria, measles, leprosy, and intestinal obstruction, 
when not of a malignant character, and probably in influenza 
and cystitis. 

Treatment should address the underlying disease. 



LEUKEMIA. 



341 



LEUKEMIA (Leukocythemia . 

Leukaemia is distinguished by a reduction of both red and 
white hlood-co r [jusdes, a relative increase of the white blood- 
corpnscles, and the general signs of anaemia. 

The disease may be conveniently c//r/r/ec/ into: (1) Splenic- 
niyelogenous leuhemia, in which there is an increased number 
of myelocvtes, corpuscles which are believed to originate in 
the bone-marrow, with little alteration in the size of the 
spleen or lymphatic glands; and (2) Liiyaphaiic IrnJxfmia, in 
which the lymphatic glands show enlargement, with an in- 
crease in the number of leukocytes and a relative increase of 
the small mononuclear leukocytes as compared with the other 
white blood-corpuscles. Mixed forms are common. 

The etiology is obscure. Most cases occur in men in mid- 
dle life. Leuhceniia is believed by many to be an infectious 
disease. Such an opinion is supported by the observation of 
Obrastow. An attendant who had charge of a case of lymph- 
atic leukaemia and came into intimate contact with the case 
began to show the symptoms of the disease forty days later. 
The case in the attendant ran a course similar to that in the 
first patient. Both cases were fatal. 

Transitions from leuktemia to pernicious anaemia, and vice 
versa, and from Hodgkin's disease to leukaemia, have been 
reported. 

Among the conditions to which leuktemia has been attrib- 
uted are malaria, syphilis, pregnancy, parturition, the climac- 
teric, mental strain, traumatism, and heredity. Leukaemia is 
probably not caused directly by any of these conditions. 

Leukaemia — symptomatology: There are the usucd syrnptoras 
of anrernia. The sJdn and mucous rnenibranes are pale, the 
patient complains of palpitcdion of the heart, early fedigue, 
shortness of breath on slight effort, and hemorrhage, especially 
episterxis. Hemorrhage in the brain may be fatal ; bleeding 
may also occur in the subcutaneous tissue, in the stomach, or 
in the bladder. Hemorrhage is most common in acute lym- 
phatic leukaemia, occurring most frequently from the gums. 
Frec|uently there is diarrhoea, which is obstinate to treatment. 
The disease affects especially the spleen, or the lymphatic 



342 



DISEASES OF THE BLOOD. 



glands, or the bone-marrow. The spleen may push the heart 
upward and interfere with its action. The liver is often en- 
larged. Dropsy is not uncommon. There is often fever, ap- 
parently without cause. 

The blood is normal in color or somewhat pale, but is not so 
fluid as normal blood. There is usually a dimunition of the 
hcemoglobin. Splenic-myelogenous leukaemia shows an enor- 
mous increase in the number of leukocytes, averaging about 
350,000 ; and also a large number of myelocytes. Myelocytes 
may be present in pernicious anaemia, but are much more 
numerous in leukaemia, averaging 37 per cent., or 80,000 per 
cubic millimetre. The polymorphonuclear cells show a rela- 
tive decrease, but absolute increase in number. Lymphocytes 
and large mononuclear cells are present in small numbers. 
There may be a slight increase in the eosinophile cells. 

In lymphatic leukcemia about nine-tenths of the white 
blood-corpuscles are small lymphocytes. A few myelocytes are 
usually present. 

Diagnosis : Affection of the lymphatics, spleen, or marrow 
of the bones, in a patient with the appearance and symp- 
toms of ansemia points strongly to leukaemia. An absolute 
diagnosis can be made by an examination of the blood, 
whereby the different varieties of the disease may also be 
recognized. 

The prognosis is bad. Most cases die within two years, and 
only very rarely does life extend beyond four years. As in 
pernicious anaemia, about the only hope is that the cause may 
be found. 

Leukaemia — treatment is symptomatic. The use of large 
doses of quinine or of Fowler's solution sometimes is bene- 
ficial. A diet made up chiefly of carbohydrates, and contain- 
ing little of the proteids, has been recommended, since it has 
been proven that the proteids are poorly assimilated. 

PSEUDOLEUKEMIA (Hodgkin's Disease). 

Pseudoleukaemia bears a strong resemblance to leukaemia. 
Transition-cases have been reported. Pseudoleukaemia is 
marked by enlargement of the spleen or lymphatic glands or 



THE HEMORRHAGIC DIATHESIS. 



343 



both ; sometimes with enlargement of the lymphatics in 
various parts of the body. 

The etiology is obscure. Many observers believe the dis- 
ease to be due to an infection. Pseudoleuksemia occurs most 
frequently in men under forty. 

Symptomatology : Aside from the symptoms of anoemia 
pseudoleukfemia is distinguished by the presence of 'pressure- 
symptoms, due to enlargements of the lymphatics or lymphatic 
glands. 

Examination of the blood reveals as a rule no increase 
of the white blood-corpuscles. Of course, an increase of 
the white blood-corpuscles may appear as a coincidence, and 
not infrequently is present in cases of suppuration of an en- 
larged gland ; but the leukocytosis is never marked ; nor is 
there much degradation of the red blood-corpuscles, except 
toward the end of the disease, when they may number only 
2,000,000. The reduction of the amount of haemoglobin 
goes along with the reduction in the number of the red blood- 
corpuscles. There may be an increase of the lymphocytes or 
of the large mononuclear leukocytes. Myelocytes are some- 
times present in small numbers, and occasionally normoblasts 
may be found. 

The diagnosis depends upon the symptoms of anaemia, the 
pressure-symptoms, examination of the blood, and the exclu- 
sion of tubercular adenitis and syphilis. When the spleen 
alone is affected, malaria, leukaemia, rickets, and amyloid dis- 
ease must be excluded. 

The prognosis is grave. Acute cases may run their course 
in a few wrecks. As a rule the course is not so rapid as in 
leukaemia. Usually the disease lasts for a number of years. 
Hope lies largely in finding the cause. Occasionally cases 
recover. 

Treatment : The best single remedy is arsenic, which should 
be given both internally and hypodermatically. Further 
treatment is symptomatic. 

THE HEMOERHAGIC DIATHESIS. 

Definition : A disposition to hemorrhage upon slight injury 
is sometimes inherited. More frequently the condition is ac- 



344 



DISEASES OF THE BLOOD. 



quired as a sequel to some infection, especially typhoid fever 
or smallpox ; less frequently yellow fever, septicaemia, or 
diphtiieria. The hemorrhage may come from the capillaries, 
per dlapedesln, or from the larger vessels, per rhexin. Bleed- 
ing occurs most frequently from the nose and intestine; less 
frequently from the mouth, lungs, bladder, uterus, etc. Triv- 
ial insult may cause hemorrhage from any surface or into 
serous membranes and internal organs (brain). 
Prognosis : Grave. 

Treatment : Epistaxis may be arrested by plugging the 
nares. In general, hemorrhage may be controlled by rest, 
ice, tampons, and the internal use of opium, atropine, acetate 
of lead, digitalis, and the subcutaneous use of ergotin and 
sclerotinic acid. Further treatment is the same as for anaemia. 

Haematidrosis (sweating of blood) : A rare condition in 
which blood-corpuscles escape through the ducts of the sweat- 
glands in the presence of an unbroken skin. 

PURPURA. 

Definition : A class of affections characterized by the ex- , 
travasation of blood into the skin. 

Symptomatic purpura may be caused by the infections, sep- 
ticaemia, and especially malignant endocarditis. Typhus 
fever, measles, scarlet fever, and smallpox are characterized 
by a purpuric rash. Toxic causes of purpura are snake-bites 
and occasionally certain drugs : copaiba, quinine, belladonna, 
mercury, ergot, and the iodides. Sometimes purpura appears 
in cancer, tuberculosis, Hodgkin's disease, Bright's disease, 
scurvy, and in old age. 

So-called myelopathic purpura may appear in locomotor 
ataxia. Purpura may also be found in acute myelitis, trans- 
verse myelitis, occasionally in neuralgia, and the stigmata of 
hysteria. 

Sometimes purpura occurs in cases of venous stasis, such as 
may occur in the paroxysms of whooping-cough and in epi- 
lepsy. 

Arthritic purpura is characterized by the affection of joints. 
In purpura simplex the process is limited to a portion of the 



HEMOPHILIA. 



345 



body, usually the lower extremities, either \Yith or without 
involvement of the joints. There is often an associate diar- 
rhoea. 

Purpura rheumatica, Schonlein's disease, is characterized by 
the alfectionof a number of joints and an eruption. Purpura 
urticans is a combination of wheals and purpura. In pemphi- 
goid purpura there is an associated vesication. Sometimes 
there is oedema, constituting the condition known as febrile 
purpuric oedema. Schonlein's disease is characterized by mul- 
tiple arthritis, purpura, and urticaria. 

Henoch's purpura usually occurs in children and is charac- 
terized by numerous relapses and recurrences, cutaneous 
lesions, affection of joints, hemorrhages into the mucous mem- 
branes, and gastro-intestinal crises : pain, vomiting, and diar- 
rhoea. Not all these symptoms are necessarily present in 
every case. 

Purpura haemorrhagica includes the cases of very severe pur- 
pura with hemorrhages from the mticous membranes. Some- 
times cases prove fatal within a day, purpura fulminans. 
Death may occur before there is hemorrhage. Favorable 
cases of purpura haemorrhagica recover in ten days to two 
weeks. The diagnosis calls for the exclusion of scurvy, and 
the recognition of smallpox and measles. 

Treatment : Any apparent cause, such as may usually be 
found in symptomatic purpura, should be properly treated. 
For further treatment see the Treatment of the Hemorrhagic 
Diathesis. 

H-ffiMOPHILIA (An Hereditary Hemorrhagic Diathesis). 

Etiology : The disease is usually transmitted through a 
mother who is not herself affected, but is the daughter of a 
bleeder. The great majority of cases occur in males, as a 
rule within the first two years of life. The skin is usually 
fine and soft, and the individuals appear perfectly healthy. 
The cause of the condition is unknown. 

Symptomatology : Slight lesions are followed by excessive 
bleeding. Usually the condition is first recognized as an epis- 
taxis ; sometimes by hemorrhage from the mouth, stomach, 



346 



DISEASES OF THE BLOOD. 



bowels, urethra, lungs ; more rarely from the skin of the head, 
tongue, finger-tips, tear-papilla, eyelids, external ear, vulva, 
navel, or scrotum. Even so slight an operation as the extrac- 
tion of a tooth may prove fatal. Traumatisms that do not 
cause lesion of the skin or mucous membrane may be followed 
by the formation of petechise- or even large hsematomata. 
There is often arthritis, involving especially the large joints. 

Prognosis : The outlook is grave, although individuals usu- 
ally do not die from the first hemorrhage. The disease may 
be persistent even for years, so that the individual exception- 
ally may reach an advanced age. 

Treatment : As prophylactic measures, individuals known 
to be bleeders or from suspicious stock, should be guarded 
from injury and not subjected to operations. The daughters 
in bleeder families, even though apparently unaffected, may 
transmit the disease to their descendents, without themselves 
showing any evidence of haemophilia. 

When bleeding occurs the usual remedies for the control 
of hemorrhage should be tried. As styptics, a solution of 
fibrin-ferment and sodium chloride, the application of fresh 
blood, and the use of a 5 per cent, solution of gelatin, have 
been recommended. 

Further treatment is addressed to the general condition of 
the patient, with exercise in the open air, nutritious food, and 
the use of tonics, especially iron and cod-liver oil. 

SCURVY (Scorl)iitus). 

Definition : A disease characterized by hemorrhage, spongy 
gums, cachexia, and marasmus. 

Etiology : The disease seems to depend upon an imper- 
fect food-supply, especially the absence of those elements 
of food supplied by fresh vegetables. Many observers be- 
lieve the true cause to be some micro-organism. Others 
would attribute the disease to a decreased alkalinity of the 
blood. Probably both views are correct. 

Symptomatology : The onset is insidious. There are jpro- 
gressive loss of sti^ength and weight, and the anaemia and de- 
pression of spirits characteristic of cachexia. The gums are 



ADDISON'S DISEASE. 



347 



swollen and Need easily, become spongy, ulcerated, necrosed, 
and covered with foetid debris. The affection of the gums is 
confined to the region of the teeth. The breath is offensive. 
Epistaxis is frequent. Soon there is the picture of a general 
hemorrh agio diathesis. 

Diagnosis: The recognition of scurvy is easy in the pres- 
ence of an epidemic. Isolated cases mav be recognized by 
kno^vledge of the character of the food used by the indi- 
vidual, in the presence of characteristic symptoms, and the im- 
provement of the symptoms following the use of proper food. 

Prognosis : Much depends upon the strength of the patient^ 
the stage of the disease, and the ability to secure proper food. 

Prophylaxis: The disease may be prevented by the use of 
fresh food, especially vegetables. 

Scurvy — treatment : At first the juice of lemons or oranges 
may be given ; later, apples, lettuce, potatoes, cabbage, water- 
cress, sauer-kraut, spinach, onions, dandelions, and other 
fruits, vegetables, and greens may be added. The mouth 
should be cleaned and kept clean. Various antiseptic and 
astringent washes are recommended : peroxide of hydrogen, 
solutions of creolin, permanganate of potassium, and dilute 
carbolic acid. The gums may be treated with a solution of 
nitrate of silver. Constipation is best relieved by enemata. 

ADDISON'S DISEASE Morbus Addisonii ; Bronze-skin Disease). 

Definition : An affection of the suprarenal capsules, charac- 
terized by pigmentation of the skin, progressive angemia, 
cachexia, gastro-intestinal catarrh, depressed circulation, and 
marasmus. 

Etiology : The disease is rare in this country. Males are 
most frequentlv attacked. The most common lesion is tuber- 
culosis of the suprarenal capsules. The disease depends upon 
a loss of function of these bodies. Carcinoma of the supra- 
renal capsules is rare. Traumatism seems to play a role in 
some cases. 

Addison's disease — symptomatology: Usually the onset is 
insidious, with a Hcez/i/o a)id genercd debility. The action of 
the heart is feeble. There are symptoms of gastro-intestinal 



348 



DISEASES OF THE BLOOD. 



catarrh, nausea, and vomiting, later pain and retraction of 
the abdomen, sometimes severe anorexia, and at times diar- 
rhoea. The most characteristic lesion is the bronze pigmenta- 
tion of the skin, which may vary in color from light yellow to 
brown or even black. The pigmentation occurs first where 
there is normally a deposit of pigment, around the nipples 
and genitals ; or where there is some irritation of the skin, as 
about the waist-band. The mucous membranes of the mouth, 
conjunctivse, and vagina show pigmentation. There may be 
patches of pigment in the serous membranes. Usually the 
bronze color is first observed on the face and hands. The 
pigmentation may be diffuse. There is degeneration of the 
suprarenal bodies. 

Diagnosis : The recognition of the disease depends upon 
the presence of the characteristic pigmentation, progressive 
cachexia, and marasmus. 

Differential diagnosis has to do chiefly with the separation 
from abdominal tumors, pregnancy, disease of the liver, pedic- 
ulosis, argyria ; more rarely exophthalmic goitre, melanotic 
cancer, scleroderma, ulcer or dilatation of the stomach, and a 
free eruption of small black comedones. 

Prognosis : Unfavorable. Rapid cases may reach a fatal 
termination in a few weeks. Protracted cases may last a 
number of years, sometimes with periods of improvement 
lasting for months, rarely with complete recovery. The out- 
look is usually best in the cases with most marked pigmentation. 

Addison's disease — treatment : The suprarenal capsule may 
be administered raw, partially cooked, or in the form of the 
glycerin extract or the dried extract. In a collection of 48 
cases treated in this manner, 22 were improved and 6 were 
reported cured (Kinnicutt). Further treatment is symp- 
tomatic (see Ansemia). 

LITH^MIA (Uric-acidemia ; Uricaemia ; Lithuria; Lithic-acid 
Diathesis; Uric-acid Diathesis; American Gout). 

Definition : An excess of lithic (uric) acid in the blood with 
the production of symptoms, especially on the part of the 
nervous and digestive systems. 



GOrT. 



349 



Etiology : Lithtemia occurs chiefly in inclivirlnals are 
subjected TO mental strain, worry, and anxiety, who eat too 
much, drink too little, and siifl'er from lack of exercise. To- 
bacco and alcoh"! often seem tn play a ro^^. in cau-ation. 
Other factors arc heredity, cnld climate, and n^rurotic teniper- 
ament. 

Lithsemia — symptomatology : The more C' lmmon iiervous 
si/injjfoins are neuralgia, headache, vertigo, hebetude, insom- 
nia, restlessness, and hypocliondriasi-. On the part of the 
digestirf siisfrra there are coated tongue, lost or capricious ap- 
petite, pyrosis, weight and opjU'essiun in the epigastritirn. 
sometimes nausea, vomiting, and gastraleia. There are flatu- 
lence, cunstipati'jn. ofl'cnsive st<j'jl~. hemurrli'jid-. sometimes 
hepatic tenderness. The d:in may shuw pruritus, eczema, ur- 
ticaria, and lichen. (^^/uto-urinari/ s^'mptLan- are urethritis, 
cy-titi-. ''rchiti-. epididymitis, vaginitis, and end'jmetritis 
And^?r- : inflammations that are caused hy slight insult in 
the presence of litlitcmia. 

The diagnosis is made by the presence of a number of the 
above symptoms. True gout gives a family history of the 
disease, and pre-ents tophi and distorted joints. 

Prognosis : Usually good under proper treatment. 

Lithsemia — treatment: The individual must change his 
habits of life and suljject himself to less Avcrry and excite- 
ment. He rnu-t eat les-. e-pecially of meats and rich f:"Al. 
and drink an aljundance of pure water. The cause must be 
removed. Outdoor life and bathing are beneficial. In the 
way of medicines, sodium phosphate and salicylic acid are of 
value for their action respectively upon the liver and excre- 
tion of ttrea. Further treatment is symptomatic. 

GOUT 'PodagTa\ 

Definition : A disease characterized l:)y an excessive forma- 
tion of uric acid : and the deprisitirai of urate of sodium 
in the joints : marked Ijy piaruxysmal ])ain and def_">rmity 
of the joints, with atfection of the heart and kidneys, and 
marasmus. 

Etiology : There is a disturbance in metabolism, with ex- 



350 



DISEASES OF THE BLOOD. 



cessive formation of oric acid. Cases have been observed in 
infancy ; but, as a rule, the disease occurs late in life. Hered- 
ity seems to play a role in more than half the cases. Gout 
shows a preference for males. Rich food, the ingestion of 
alcohol, especially beer and ale, are the most prominent factors 
in etioloo^v. The disease often occurs in cases of chronic 
plurabism. 

Gout — symptomatology : The onset of the disease is usually 
sudden. The attack comes on often late in the night, with 
pain of greater or less severity, amounting at first sometimes 
only to a feeling of uneasiness, localized in a joint, usually the 
joint of the big toe. The pain becomes excruciating. The 
attack ceases in the course of an hour or two. The individ- 
ual resumes his sleep ; and in the morning the joint is found to 
be redy swollen, tender, and the movements limited. Such at- 
tacks come on in the midst of apparent health, more often 
following dyspepsia. The attack maybe repeated the follow- 
ing night, or after a much longer interval, a month or year, 
depending upon the habits of the individual, especially with 
regard to the diet. 

Chronic cases show characteristic deformities of the joints, 
due to the deposit of the urate of sodium. There are 
chronic gastric catarrh, arteriosclerosis, and afection of the 
heart and kidneys. The enlarged joints may show ulceration, 
with the discharge of a substance composed largely of urate of 
sodium. The enlargements at first show fluctuation, later pre- 
sent a doughy sensation, and still later become hard tophi. 

Gout — diagnosis : Usually there are dyspepsia and other 
evidence of over-indulgence in rich food and alcohol, espe- 
cially the malt preparations, beer and ale. The polyarthritis 
usually, but not invariably, begins in the joint of the big toe. 
The inflammation remains fixed in the joints affected, which, 
together with the overlying tendons, become characteristically 
deformed through the deposit of urate of sodium in tophi 
(Fig. 37). Gout prefers the small joints. Males are most 
frequently affected. Examination of the urine shows the 
elimination of little or no uric acid during the paroxysm ; 
during the interval the excretion of uric acid is greatly in- 
creased as a rule. Sometimes gout finds expression in con- 



GOVT. 



351 




jnnctivitis. iriti-. corneal ulcer : or the deposit of tophi in 
the ear. nM:>e. eyelid-, arjd larynx. 

Gout should be d[rTrr^:idinf^:d from rheumatism, especially 
from arrhriri- detdrmans. in which the disease usually begins 
in the hands and nrjre fre- 
quently involves the larger 
j'dnt-. There is usually 
little rir ni) fever in g'jut. 

Prognosis : Glmh:] in acute 
gout. Chronic gout may 
take life through di-ease of 
the kidney-, heart, t'lr brain. 

Gout — treatment : ALj,-t 
important is the regulati'jn 
of the life of the indiviilual, 
especially as to diet and ex- 
ercise. The u-e of artiticial 
alkaline mineral water, or 
better a soj^airn at tlie 
spring-, may -'jmetimes suf- 
fice even with'jiu the use of 
drugs. The waters usually 
recommended are Vichy. , 
Carlsljad. and the litbiated 
water-. The mn^r pii|;»ular 
spring- are thij-e C'arl-- 
bad. Homberg. AAdldljad. in 
Germany : Gontrexeville 
and Aix-les-Bains. France; 
Bath ant:l Bnxt'_'n. in Eng- 
land: and Sarat'i-a. Bed- 
ford, au'] tip/ A\diite Sulphur Springs in this country. 

In the wav (if (li'iiris. niM-r may l)e aecranplislied with the 
wine of colchicimi. piperazin. and the -alieylates. The limb 
>h;iuld In? wrapped in eMtt^n-wi i. .1. The Incal ai^plication (^f 
hot air jnay ije tried. Tiie b^iw-. l- sliordd ht- kept nj3en. Cal- 
omel is often nf v;djM- e-arlv in tiie di-ea-e. Occasicmally 
cases may be benerited liy tije iudides. Further treatment is 
symptomatic. 



Tophi in joints and tendons. 



352 



DISEASES OF THE BLOOD. 



ARTHRITIS DEFORMANS (Nodular Rheumatism). 

Definition : A chronic disease of obscure etiology, charac- 
terized by progressive, symmetrical deformity of the joints. 

Etiology : Many observers believe the disease to be a chronic 
infection ; others that it is of nervous origin. Most cases are 
found bet\veen thirty and fifty years. The great majority of 
cases occur in women. Heredity sometimes seems to play a 
role. There is a history of gout oftener than of true rheu- 
matism. Exposure to cold, wet, damp, errors in diet, de- 
pressing mental emotions, prolonged sorrow, grief or dejection, 
are prominent factors in causation. 

Arthritis deformans — symptomatology : Usually the onset is 
insidious. Affected joints first become stiff] especially in the 
morning, and tender, and later show characteristic deformity. 
The joints of the hands and fingers are usually first attacked. 
The fingers are flexed upon the hand and point toward the 
ulna ; the thumb is not effected. When the disease attacks the 
foot, the big toe is first involved. The joints become locked, 
so that in cases of extensive involvement of the joints the patient 
may become immovably fixed in the position usually occupied. 
The disease is marked by great deformity. With exacerba- 
tions and abatements the disease is progressive. There are im- 
pairment of the appetite and digestion and constipation, largely 
due to lack of exercise. The j)atients become irritable and 
hypochondri((ccd . The muscles undergo atrophy. 

Diagnosis : The only difficulty is offered early in the course 
of the disease. The disease prefers the female sex, and is 
comparatively rare under twenty. Permanent deformities are 
produced in the joints affected. Fever is usually absent. 
The disease is polyarticular and shows preference for the 
sniall joints. The hands and fingers, but not the thumbs, are 
usually first involved. 

Prognosis: The disease does not seem to shorten life. It is 
chronica, and may be relieved, but not cured. 

Arthritis deformans — treatment : The pain may be relieved 
by hydrotherapy and massage, w^hich also assist the nutrition 
of the muscles. Electricity is sometimes of value. Arsenic 
probably does good as a tonic. Iron may be indicated by 



RICKETS. 



353 



anemia. Iodine, best in the tincture, gtt. x, or the iodide of 
potassium or sodium, given in milk, is recommended. Sali- 
pyrin, salol, and the salicylates, and phenacetin may be ad- 
vantageously used during the acute exacerbations. Massage 
and the local application of hot air sometimes produce good 
results. Blisters are of value, especially in chronic cases. 
Often a change of climate is advisable. 

RICKETS (Rachitis). 

Definition : A disease of infancy and childhood, character- 
ized by gastro-intestinal disturbances, bronchial catarrh, im- 
paired nutrition, and changes in the boues. 

Etiology : Some observers attribute the disease to a chronic 
infection. An essential factor seems to be a faulty diet, espe- 
cially one deficient in animal fat and proteid (Cheadle). The 
disease is most frequent from seven months to seven years, 
rare under six months, and in exceptional cases appears as 
late as the ninth to the twelfth year. 

Rickets — symptomatology : There is early gastro-intestinal 
disturbance, marked by anorexia, and diarrhcea or constipation. 
There are bronchial catarrh and cough. The child becomes 
restless at night. Sweating occurs, often without apparent 
cause. There is genercd soreness, especially sensitiveness of 
the body. Sometimes cases are announced suddenly by a 
spasm, especially by laryngo-spasm. There is slight fever. 

The bones show characteristic deformities. Nodules may be 
observed at the junction of the ribs and costal cartilages, 
i forming the rickety rosary. The sternum projects, to form 
I the pigeon- or chicken-breast. The upper part of the head is 
large, compared with the face and body of the child. Often 
softened spots may be made out over the bones of the skull, 
^ especially the occipital bone. The fontanelles do not close early. 
i The top of the head is more flat than normally. The frontal 
I eminences are prominent. The teeth appear late and often are 
' ill formed. The child grows sloidy ; usually the stature is 
below the normal. The bones are soft ; hence, the frequency 
of bow-legs. The abdomen is usucdly large a nd distended. The 
j bones easily suffer fracture, especially the green-stick fracture. 

23— P. M. 



354 



DISEASES OF THE BLOOD. 



Most dwarfs are rickety. Deformity of the pelvis is often 
caused by rickets. 

Diagnosis : The disease is recognized by the characteristic 
changes in the bones. 

Prognosis : Good. Fatalities depend upon complications. 

Rickets — treatment : Malnutrition may be avoided by atten- 
tion to the diet of the child. In cases of rickets the diet should 
include some fruit, such as lemon- or orange-juice. The 
child should be placed under good hygienic surroundings, 
receive plenty of pure, fresh air and sunshine, and a daily 
warm batb. When the bones are soft the child should not be 
permitted to remain in one position too long. 

Of drugs, phosphorus has the best reputation. The remedy 
is given in cod-liver oil, 1 : 16, a teaspoonful after meals, 
three times a day. The syrup of the iodide of iron may be 
added. Further treatment is symptomatic. 

OSTEOMALACIA. 

The disease is characterized by softening and consequent 
deformity of the bones. 

Etiology : Numerous micro-organisms have been found in 
osteomalacia. The bones contain an excess of lactic acid ; 
but this is sometimes found in the absence of osteomalacia. 
Some observers believe the condition due to a disturbance 
of the centres that preside over nutrition. 

Symptomatology : The bones become tender, and pain is 
often first noticed in the pelvis, spine, and thighs, especially 
during the latter part of gestation. The muscles of the thighs 
and pelvis may suffer weakness, pain, and spasm. The 
affected bones become soft and sliow deformity. The stature 
of the individual is diminished (StriimpeH). Increased knee- 
jerk and ankle-clonus are prominent symptoms. The disease 
is confined almost exclusively to the female sex. The affected 
women are usually above the average in fertility (Eisenhart). 
Abortion is frequent. The blood shows diminished alkales- 
cence (von Jaksch), and contains myelocytes and an increased 
number of eosinophilic cells (Musser). 

Diagnosis : The disease may be suspected in the presence of 



OBESITY. 



pain in the pelvis, spine, and thighs, in women, especiailv 
when the pain recurs in succeeding pregnancies. U-uallv the 
height is diminished. The softening and deformity of the 
aifected bones are characteristic. 

Differential diagnosis has to do chieflv with rheumatism, 
spinal disease, peripheral neuritis, and dilfase infiltrarion lof 
bones with malignant growths. 

Prognosis : The disease is usually progressive : but may fre- 
quently be brought under control by proper treatment. 

Osteomalacia — ^treatment : The use of phosphorus (Stem- 
berg) and cod-liver oil (Trousseau) has given good results. 
In the way of surgery, ovariotomy and Porro's operation have 
both been followed by recovery in a large number of instances. 

OBESITY Polysarcia; Corpulence . 

Definition : An excessive general deposit of fat. 

Etiology : Obesity occtirs especially after forty. Sometimes 
the condition appears in young persons. The chief causes 
are excessive eating and sleeping and lack of exercise. 
AVomen are most frequently atfected. 

Symptomatology : The development of fat may be termed 
obesity only when it accumulates to such a degree as to inter- 
fere with the comfort and health of the individual. 

Treatment : The individual should eat less, take more exer- 
cise, best in the open air, and less sleep. The ingestion of 
fluids should be limited. Probably the best dietaries are those 
given by Banting, Ebstein, and Oertel. Banting reduces the 
amount of food and drink, and excludes the fats and carbo- 
hydrates. Ebstein permits the use of fats and excludes the 
carbohydrates. Oertel limits the fat, and permits the use of 
albumin and starch, and advises systematic exercise for the 
purpose of increasing the strength of the heart. Skimmed 
milk and massage are recommended by W^eir Mitchell, Warm 
baths are of value. Sometimes good results may be secured 
by the use of the thyroid extract. 



356 



DISEASES OF THE BLOOD. 



DIABETES MELLITUS. 

Definition : A disease characterized by polyuria, glycosuria, 
and progressive impairment of health and strength. 

History : Celsus recognized the polyuria and emaciation. 
Glycosuria was suspected, from the sweet taste of the urine, 
by the Arabian physician Susruta, in the seventh century, and 
became generally known when re-discovered by Thomas 
Willis (1674). The sweet taste was proven to depend upon 
sugar by Matthew Dobson (1775). Cowley (1778) separated 
the sugar by evaporation. Rollo (1798) introduced the meat- 
diet and the use of opium in the treatment of diabetes. 
Chevreuil (1815) observed that the sugar of diabetic urine is 
the same as grape-sugar. Tiedemann and Gmelin discovered 
the formation of sugar from starch during digestion. Am- 
brosiani (1835) found sugar in the blood of diabetic patients. 
This Mialhe believed to be due to diminished alkalescence, 
caused by suppression of the secretion of the skin. Stosh 
(1828) observed diabetic coma. Bernard (1856) produced 
glycosuria by puncture of the floor of the fourth ventricle. 
Marchel (1852) recognized diabetic gangrene. Frerichs and 
Von Recklinghausen (1866) observed disease of the pancreas 
frequently in diabetes ; and later Merino^ and Minkowsky 
found diabetes to follow extirpation of the pancreas. 

Etiology : The disease is found more frequently in some 
places than others. Certain races, for instance, the Israelites, 
are frequently affected ; while others, especially the negro, 
seldom show the disease. Most cases occur in the male sex, 
and at from twenty to fifty years of age, especially between 
thirty and forty. Only about one-fourth of the cases are 
found in the female sex. Age and infancy are not exempt. 
Sometimes heredity seems to play a role. Diabetics often 
show disease of the kidneys, blood, nervous system, and pan- 
creas ; but diabetes may occur in the absence of disease of 
these organs. 

Anxiety, luxury, alcohol, and obesity are prominent etio- 
logical factors. Most cases show arterio-sclerosis. Syphilis 
probably plays a minor role. Diabetes sometimes appears 
after trauma, in the course of or after nervous diseases, emo- 



DIABETES MELLITUS. 



357 



tional disturbances, and the infectious diseases. The belief 
has been advanced that diabetes is contagious. 

Diabetes follows total extirpation of the pancreas ; but if 
more than one-tenth of the organ be left, diabetes does not 
result. It has been demonstrated experimentally that removal 
of the pancreas is not followed by diabetes if at the same time 
the medulla or spinal cord be divided in the region of the 
upper cervical vertebra. Also, experimental removal of the 
pancreas is not followed by diabetes if the liver be removed 
at the same time. 

Diabetes mellitus — symptomatology : The onset is insidious, 
with anorexia, nausea, headache, and insomnia, symptoms 
usually ascribed to dyspepsia or neurasthenia. There are 
thirst and polyuria, urine discharged in the twenty-four 
hours amounting to more than three pints, usually four to 
eight pints, sometimes more. 

The urine is light colored and foams readily. The reaction 
is acid ; the specific gravity high, 1030-1040, rarely lower 
than 1020, nor higher than 1050. Trousseau reported as 
high as 1074. There is glycosuria, the amount of sugar 
varying from 2 per cent, or less in mild cases, to as high as 
10 per cent. Rarely there is pneumaturia, gas discharged 
with the urine. Other abnormal ingredients found in dia- 
betic urine are acetone, acetic acid, ammonia, and oxy- 
butyric acid. The proportion of cases showing albuminuria 
has been variously given by different observers. Frerichs 
found albuminuria in 5 per cent, of cases ; Rokitansky, in 65 
per cent. There is not often cedema. Sometimes there is 
cystitis. The urine may contain short hyaline casts. 

The appetite is sometimes voracious and insatiable. Never- 
theless there \^ pyrogressive impairment of health and strength. 
As a rule there is constipation. Often there is impotence. 
The knee-jerk may be diminished or lost. The increased 
secretion of urine is in marked contrast with the lessened secre- 
tion of the skin. Often there is pruritus, especially pruritus 
vulvae and furunculosis, sometimes phlegmonous inflamma- 
tions and gangrene. Cataract is not infrequent. 

Among the nervous symptoms are headache, neuralgia, par- 
scsthesia, and coma. Tubei-culosis is a frequent complication. 



358 



DISEASES OF THE BLOOD. 



Diabetes mellitus — diagnosis : 1, impairment of health ; 2, 
increased quantity of urine ; and 3, the presence of sugar in 
the urine. Glycosuria may be detected by the following 

Tests for Sugar: 

Bremer's test : The specific gravity of the urine must not 
be less than 1015. To 10 c.c. of urine, at a temperature of 
14^ or 15° C, in a test-tube, add gi'. 3V~to methyl-violet 
or etliylene-blue. Normal urine does not dissolve methyl- 
violet ; diabetic urine dissolves tlie dye and assumes a deep 
violet or bluish-violet tint. When ethylene-blue is used, 
normal urine gives a green color, and diabetic urine a blue. 
The test gives a positive reaction when normal urine is dihited 
with water. Thus tlie Bremer test might be of value in life- 
insurance examiuatioDS, in the detection of fraud, when indi- 
viduals are susj^ected of diluting the urine in order to give a 
lower specific gravity. 

Moore's test : To a test-tube one-third full of urine an 
equal quantity of concentrated KHO is added and heat ap- 
plied. Sugar is indicated by a brownish color. 

Trommer's test : To equal quantities of urine and concen- 
trated KHO add 1 p:r cent, solution of copper sulphate, drop 
by drop, under gentle heat, as long as the copper sulphate 
will dissolve. Sugar gives a yellowish or reddish precipitate 
before the boiling-point is reached. 

Hain's test : Hain's fluid : copper sulphate, gr. xxx ; glyc- 
erin, .^ss ; aqute, 3ss ; liquor potassae (U. S. P.), 5v. Heat the 
test-fluid and add four or five drops of urine. Sugar gives a 
yellow or red, salmon-colored precipitate. 

Bottger's test : To equal quantities of urine and KHO add 
bismuth subnitrate and apply heat. Sugar gives a black color. 
The test is useless in the presence of albumin. A better bis- 
muth test is : 

Nylander's test : IN'ylander's reagent : Kochelle salt, 4.0 ; 
8 per cent, solution of XaHO, 106.0; add bismuth sub- 
nitrate to saturation. 

Method: To ten parts of urine add one part of the reagent 
and boil two minutes. A black color indicates sugar. 



DIABETES MELLITUS. 



359 



Phenyl-hydrazin test : To 6-8 c.c. of urine add phenvl- 
hydrazin hydroehlorate (^twice a< much as will go on the point 
of a penknife) and pulverized acetate of sodiinn (three point- 
of-a-penknifefuls). Heat. If the reagent does not dissolve, 
add hot water. Cool. If sugar is present, there will Ije formed 
a yellow precipitate, which may appear amorphous to the naked 
eye, but under the microscope will be seen to consist of fine 
needles of phenyl-glucosazon arranged in stars (Fig. 38). 




Fermentation-test : To 10 c.c. of urine add 1 gramme of 
commercial compressed yeast Fleischmann cake). Shake 
until the yeast is dissolved. Place in a saccharometer and 
leave at the room-temperature for twenty-four hours. In the 
presence of sugar alcoholic fermentation catises the formation 
of carbonic acid gas, wliich gathers at the top of the saccha- 
rometer and causes the fluid to change its level. The percent- 



360 



DISEASES OF THE BLOOD. 



age of sugar may be read off the scale. When the specific 
gravity is above 1022 the urine should be diluted from two 
to ten times, depending upon the height of the specific gravity, 
and the reading of the saccharometer should then be multi- 
plied accordingly. 

Roberts has observed that urine after fermentation is of 
lighter specific gravity than before, and that the difference 
in specific gravity is such that every degree lost is approxi- 
mately equivalent to one grain of sugar (glucose). The test 
may conveniently be made by dissolving a cake of Fleischmann 
yeast in four ounces of urine, taken from the total quantity 
passed in the twenty-four hours, and placing in a pint bottle 
in a warm place for twenty-four hours. The bottle should be 
loosely corked, to permit the escape of the carbonic acid gas. 
Four ounces of the urine, tightly corked, are used as a con- 
trol-specimen. At the end of twenty-four hours the specific 
gravity of the two specimens is taken ; the difference repre- 
sents the amount of sugar in grains, and this multiplied by 
0.23 will give the approximate percentage of sugar. 



Prognosis : As a rule, which is not invariable, the outlook 
depends upon the amount of sugar in the urine. Most cases 
are not curable, but usually the disease may be brought under 
such contr(>l that the patient may live to an advanced age. 
In general, the patients hold their fate in their own hands, for 
the outlook de})ends largely on the diet. Severe nervous 
symptoms, especially coma, are ominous. 

Cases of acute diabetes, diabetes acuta and acutissima, may 
terminate in a few weeks or months. As a rule diabetes is 
chronic, lasting for a number of years or for life. 

Diabetes mellitus — treatment : Most important is the diet 
The following diet-list is given by Van Noorden : 

8 o'clock, f ? f 

first breakfast. ) ^I'P 

I 1 glass ot cognac. 

second breSfa^t. { ^ ^gg^- <"ed in J ounce of butter. 



DIABETES MELLITUS. 



361 



12.30 o'clock, 
luncheon. 



5 ounces of cold roast meat. 
Mayonnaise-, made with the yolk of 1 egg 

and 1 spoonful of oil. 
Raw cucumber, with -J- ounce of vinegar. 

1 spoonful of oil. salt and pepper. 
\ ounce of Gorcronzola cheese. 



5 O'clock, 
tea. 



1 bottle of Moselle. 

1 cup of colfee with tablespnonful of 
cream, 
j' 1 cup of tea. 
1 bulled es'S". 
1 glass of cognac. 

1 cup of bouillun. with \ ounce of mar- 
row. 

2-1- ounces of boiled salmon. 
_ |- to ^ pound of asparagus, with | ounce 
7.30 o'clock, of butter. 

dinner. j 1 ounce of smoked ox tongue. 

3 ounces of capon. 

Salad, with i ounce of vinegar and 1 
spoontul of oil. 
bottle of Burgundy. 

10.30 o'clock. r 
nightcap. | 

Of drugs, opium is one of the most valuable remedies, but 
may be used only a short time. Codein has much of the 
virtue of r>pium with fewer evils. Some cases re-pond well 
to benzosr)l. the Ijenzoate of guaiacol. in live-grain capsules, 
one every four hours. Often go^d results may be obtained 
^ith Jamlnd. the Java plum, or in the form c>f the fluid ex- 
tract. ]]] X, in powders of five to ten grains, gradually increased 
to gr. 75-15''. Relief is sometimes afforded by salicylate 
of sodium. 5-10 grammes, or benzoic acid. 3-5 grammes. 
Coma may demand infusion of the normal salt solution (0.6 
per cent, of chloride <jf sodium i into the rectum, under the 
skin, or in bad cases into the veins. Often good results follow 
lavage. 

Gangrene calls for the intervention of suro^erv. 



1 glass of cognac, with Seltzer water. 



362 



DISEASES OF THE BLOOD. 



DIABETES INSIPIDUS. 

Definition : A disease characterized by increased secretion 
of urine, polyuria, without glycosuria. The condition differs 
from a simple polyuria, such as may follow the ingestion of 
large quantities of fluid, chiefly in that there is impairment 
of the general health. 

Etiology : The disease shows a preference for youth and for 
the male sex. Cases have been observed after traumatism, 
sunstroke, violent emotion, sometimes excessive drinking of 
cold water, or after a protracted spree, or during convalescence 
from the acute infections. Many believe the condition to be 
of nervous origin. Sometimes lesions of the medulla, tumors 
of the brain, meningitis, have been found in cases of diabetes 
insipidus. The disease is sometimes congenital. Weil reports 
twenty-three cases in four generations in a family of ninety- 
one members, which would seem to indicate a role played by 
heredity. 

Symptomatology : The iirine is iner eased in quantity to 
twenty, forty, or more pints in the twenty-four hours, and is 
of low specific gravity, 1001-1005, light in color, and con- 
tains little sediment. With the discharge of so much fluid 
there is thirst. There may be no impairment of the gen- 
eral health. 

Diagnosis depends upon the discharge of a large quantity 
of urine of low specific gravity, without the presence of 
sugar. The polyuria of hysteria may be eliminated by the 
absence of other evidence of hysteria. Furthermore, hys- 
terical polyuria is more transitory. Bright's disease may 
sometimes give a large quantity of light urine, but there 
is always some albuminuria, which is rare in diabetes in- 
sipidus. 

Prognosis : The disease usually runs a chronic course. 
Medication seems to have little efl^ect as a rule. Sometimes 
spontaneous recovery takes place. Cases have been known to 
persist as long as fifty years. Usually death results from 
some intercurrent malady. 

Diabetes insipidus — treatment : Opium will diminish the 
amount of urine, but is of doubtful value because of the re- 



DIABETES INSIPIDUS. 



863 



mote evils attending its use. Thirst should be relieved by 
frequent rather than copious libations. Among the remedies 
recommended are valerian, the valerianate and lactate of 
zinc, ergot, ergotin, antipyrin, antifebrin, the salicylates, 
arsenic, strychnine, turpentine, and the bromides. Open-air 
exercise and the use of electricitv are often of value. 



CHAPTER YI. 



DISEASES OF THE GENITO-URINARY ORGANS. 
ALBUMINURIA. 

The presence of albumin in the urine, abnmiDuria, is caused 
almost entirely by the transudation of blood, especially serum- 
albumin, from the bloodvessels into the tubules of the kidney. 
The exfoliation of a large number of epithelial cells may give 
rise to a trace of albumin in the urine. 

Etiology : Albuminuria does not always depend upon dis- 
ease of the kidneys. Small quantities of albumin may some- 
times be found in the urine in pregnancy, after severe and 
prolonged exertion, and after the ingestion of large quantities 
of food, especially albuminous food, eggs, cheese, pastry, par- 
ticularly when not properly digested, and when the individual 
indulges in exercise immediately after eating. 

Albuminuria may result from some change in the composi- 
tion of the blood, as in anaemia and some cases of puerperal 
eclampsia, without inflammation of the kidney. In some 
puerperal cases, and in chronic congestion of the kidney, al- 
bumin appears in the urine as the result of changes in the 
blood-pressure. Some cases of albuminuria are due to changes 
in the walls of the capillaries not of an inflammatory char- 
acter. 

More important and numerous are the cases of albuminuria 
due to disease of the kidney, inflammation of the walls of the 
capillaries, which thus more readily permit transudation. To 
this category belong the cases of acute nephritis, the severe 
forms of acute degeneration, acute congestion, and some cases 
of chronic nephritis with exudation. 

Accidental albuminuria may be caused, outside of the kid- 
^^y? pyuria, hsematuria, the escape into the urine of 
seminal or prostatic fluid, more rarely chyluria, and not infre- 

364 



ALBUMIXURIA. 



365 



qnently by hemorrhage or transudation of serum from some 
part of the urinary tract below the kidneys. Albuminuria 
from the exfoliation of epithelial cells has been mentioned. 

Tests for Albumin. 

Heller's test: Cloudy urine should be filtered. Boil the 
urine and add concentrated nitric acid. Albumin gives a 
^Yhite precipitate. A similar precipitate may be obtained 
when patients are taking balsam, which, however, may be 
dissolved by alcohol. Phosphates are precipitated by heat 
and redissolved by the acid. Urates are dissolved by the heat. 

Potassium-ferrocyanide test : Acidify the urine with acetic 
acid, and add 10 per cent, solution of potassium ferrocyanide. 
Albumin is precipitated. 

Spiegler's test : Spiegler's test-fluid : corrosive sublimate, 
40 ; tartaric acid, 20 ; white sugar. 1 00 ; and distilled water, 
1000. 

Method: A layer of urine is allowed to flow gently upon 
some of the test-fluid in a test-tube. Albumin is indicated 
by a white precipitate formed at the junction of the urine and 
the test-fluid. 

Heller's test precipitates servm-alhiimin (and albumose w^hen 
cold). The potassiuin-ferrocyamde test precipitates serum- 
albumin and albumose. Spiegler's test precipitates serum-albu- 
min, cdbumose, and peptones. 

Peptonuria indicates suppuration somewhere in the body. 
Its determination may be of value sometimes when we can 
exclude scurvy, intestinal ulceration, and the puerperium. In 
obscure cases its absence indicates the absence of suppurative 
processes in the body. Thus it is a means of differentiation 
between suppurative and tubercular meningitis. 

Casts. 

(1) Epithelial casts are composed partly or wholly of 
epithelial cells from the tubules of the kidney, and are in- 
dicative of a parenchymatous nephritis. 



366 DISEASES OF THE GENITO-URINAEY ORGANS. 



Fig. 39. 




Hyaline casts from a case of acute nephritis. 1, plain hyaline cast; 2, granular de- 
posit of hyaline casts; 3, cellular deposit (blood and epithelium). 

FiCx. 40. 




Fatty casts from a case of chronic parenchymatous nephritis. 

(2) Blood-casts, composed of more or less perfect blood- 



ALBUMINURIA. 



367 



Fig. 42. 




corpuscles, indicate hemorrhage 
from the kidney : (a) acute con- 
gestion of the kidney, {h) acute 
inflammation of the kidney, (c) 
infarction of the kidney. 

(3) The constant presence of 
pus-casts, which are rare, may 
be due to multiple abscess of the 
kidney. 

(4) Casts composed of micro- 

FiG. 41. 



Cylindroids from the urine in con- 
gested kidneys (von Jaksch). 





Different forms of waxy easts 
(von Jakseli). 



cocci may be discharged in cases of renal sepsis (embolism), 
suppurative nephritis, and pyelonephritis. 

(5) Granular casts are found in the presence of degenera- 
tion of the renal epithelium. 



368 DISEASES OF THE GENITO-URINARY ORGANS. 



(6) Fatty casts indicate fatty degeneration, such as may be 
present in the large white kidney, or in cases of poisoning by 
phosphorus, antimony, or iodoform. 

(7) Hyaline casts point strongly to chronic interstitial 
nephritis. 

(8) Waxy " casts (broad hyaline casts) are found in amy- 
loid degeneration of the kidney. 

(9) Cylindroids, or streamers, which are not true casts, indi- 
cate irritation of the kidney. They are often present in 
lithsemia and oxaluria. 

DROPSY. 

Dropsy depends upon an increased transudation of blood- 
serum from the capillaries and diminished absorption by the 
lymphatics. Inflammatory exudation and passive dropsy may 
be caused by increased blood-pressure or some change in the 
blood, especially the injury caused by poisons (toxins) circu- 
lating in the blood. 

Dropsy due to disease of the kidneys is expressed first as 
oedema of the lower eyelids and ankles ; later, of the legs 
and serous cavities; and finally of the entire body — anasarca. 
A fatal termination may be caused by oedema of the glottis, 
lungs, or bronchi. 

UREMIA. 

Uraemia is probably a misnomer, since the so-called ursemic 
symptoms do not always follow the injection of urea into the 
blood, nor is there always an increased amount of urea in 
ursemia. 

The condition is caused by the circulation in the blood of 
some poison, possibly a toxin, that normally is excreted through 
the kidneys. 

Uraemia — symptoms: 1, headache, hebetude, somnolence or 
insomnia, and anxiety, which may occur in cases of nephritis, 
either acute or chronic, and in cases of puerperal eclampsia, 
with or without nephritis ; 2, hemiplegia and aphasia, sepa- 
rately or together in chronic nephritis or eclampsia, ascribed 
by some to an endarteritis ; 3, blindness, amaurosis, which 



PYURIA. 



369 



comes on suddenly in puerperal eclampsia and sometimes in 
chronic nephritis ; 4, general epileptiforni convulsions, in puer- 
peral eclampsia and in acute or chronic nephritis. Other 
symptoms are : muscular contractions, delirium, coma, vomit- 
ing, diarrhoea, fever, dyspnoea, and increased arterial tension, 
due to hypertrophy of the left ventricle. 

PYURIA. 

Pus in the urine, pyuria, may be recognized readily by 
microscopic examination of the urine. Sometimes pus is 
present in such quantities as to be obtrusive. 

Etiology : A heavy deposit of pus in acid urine usually 
comes from pyelitis or chronic pyelonephritis. The constant 
discharge of muco-purulent urine is usually found in con- 
junction with bladder-symptoms. Such urine, in the absence 
of vesical symptoms, especially when accompanied by the 
discharge of blood, may come from pyelitis due to the 
presence of a calculus. The intermittent discharge of puru- 
lent urine usually indicates pyelitis. 

Sometimes pus comes from outside the urinary tract. Fever 
I will then accompany the accumulation of pus, to disappear 
upon its discharge. The origin of the suppuration may be 
recognized in some cases by the presence of pain and other 
symptoms. 

Flakes or threads of pus usually come from the urethra, 
i but may come from other parts of the urinary tract, as in 
cases of pyelitis, nephrolithiasis, tuberculosis of the bladder 
and prostate, and perivesical abscess. 
I Often the presence of epithelial cells, recognized upon 
microscopic examination of the urine, in cases of pyuria, 
will aid materially in determining^ the origin of the pus. 
A careful examination, especially by palpation, should be 
j made of the entire urinary tract. The use of the cystoscope 
is often of value. As a rule the source of the pus will be 
found in the pelvis of the kidney, the bladder, or the urethra. 
As stated, pus may come from without the urinary system — 
e. g., perivesical abscess and hip-joint disease. 



24— p. M. 



370 DISEASES OF THE GENITO-UETXARY ORGANS. 



CHYLURIA. 

The presence of chyle gives to the urine a milky appear- 
ance. Sometimes the urine is more or less colored by the 
admixture of blood. The amount of fat varies from 0.2 to 2 
per cent., and may be dissolved by the addition of ether, 
whereupon the urine loses its milky appearance. 

Microscopic examination of the urine reveals the presence 
of fat. The filaria sanguinis hominis, which is a common cause 
of chyluria, is found in the urine secreted during the day, as a 
rule, and in blood withdrawn during the night (see Filaria 
Sanguinis Hominis). The chyle and filaria probably gain 
entrance to the bladder through some communication between 
the dilated lacteal channels and the urinary tract. 

HEMATURIA. 

Etiology : Hemorrhage may take place from any part of 
the urinary tract. Aside from traumatism, nephritis, and 
gonorrhoeal prostatitis, haematuria is caused most frequently 
by stone in the bladder, tumors of the bladder, stone in the 
kidney, tuberculosis of the bladder, tuberculosis of the pros- 
tate, carcinoma of the kidney, cystitis, and enlarged prostate. 
Some cases are due to the distorna haematobium. 

An effort should be made to determine the cause of the 
hsematuria. Some knowledge may be gained by observing 
the color of the urine, the presence and shape of clots of 
blood, the time at which the blood is discharged in the stream 
of urine voided, the intimacy with which the blood is mixed 
with the urine, and the microscopic examination of the 
sediment. 

A careful physical examination should be made of all 
accessible parts of the urinary tract, the kidneys, ureters, 
bladder, prostate, and testicle by palpation, and if necessary 
by the use of the endoscope and cystoscope. 

Haematuria may occur in some of the infectious diseases, 
especially in measles, smallpox, typhus fever, septicaemia; 
cholera, malaria, scurvy, and in the hemorrhagic diathesis. 
Certain drugs, especially cantharides and turpentine, may 
cause haematuria, 



PYELITIS. 



371 



PYELITIS. 

Pyelitis is an inflammation of the pelvis of the kidney. 

Pyelonephritis is a conjoint inflammation of the substance 
and pelvis of the kidney. AYhen suppuration extends 
to cause destruction of tlie kidney-substance and form a 
large abscess-cavity the condition is known as pyonephro- 
sis. The involvement of surrounding tissues leads to peri- 
nephritis, pciranepjhritis, and sometimes to the formation of 
abscess. 

Inflammation of the pelvis of the kidney, pyelitis, may be 
pHmary, caused by the discharge of some irritating sub- 



FiG. 43. 




Cellular elements from the urine. 1, squamous epithelium ; 2, red blood-corpuscles; 
3, polynuclear leukocytes : 4. transitional cells ; 5, epithelium from the kidneys; 
6, epithelium from tlie pelvis of the kidney and the bladder; 7, micrococcus 
urese ; 8, yeast-fungi. 

stance through the kidney ; or secondary, caused by infection 
travelling from below upward along the urinary passages. 
Thus, the cause may come from above, as in tuberculo.^is 
of the kidney; or the passage of micro-orr/anisrns, more 
especially the toxins, toxalbumins, of the infectious dis- 



372 DISEASES OF THE GENITO-UBINARY ORGANS. 



eases — typhus, typhoid fever, septicaemia, influenza, small- 
pox, scarlet fever, diphtheria, tuberculosis, or cholera ; or 
the elimination of certain drugs — cantharides, turpentine, or 
copaiba. 

The most frequent local cause of pyelitis is kidney-stone. 
Some cases depend upon traumatism. 

The cause may come from below, from a cystitis, gonorrhoea, 
or the use of unclean instruments. 

Pyelitis — symptomatology : There is dull imin, radiating 
from the kidney along the ureters to the bladder. More 
often there is a feeling of tension and weight in the region of 
the kidney. The urine contains pus, sometimes blood, and 
albumin, and the tailed epithelial cells normally found in the 
pelvis of the kidney. The urine is acid in reaction, or becomes 
alkaline only when there is retention. 

Diagnosis : There is pyuria, sometimes hsematuria and albu- 
minuria, and the discharge of characteristic epithelial cells. 
The presence of hebetude, the typhoid state, with chills and 
fever, would indicate pyelonephrosis. 

The prognosis is serious, but depends largely upon the 
cause. Cases dependent upon cystitis or kidney-stone usually 
disappear upon the relief of these conditions. When due to 
the infections, much depends upon the nature of the infectious 
agent. The outlook is- better after typhoid fever than after 
septicaemia. 

Pyelitis — treatment : In the way of prevention, only clean 
instruments (catheters) should be used ; kidney-stones should 
be removed : gonorrhoea properly treated. The kidney may 
be flushed by the free use of water, which is best adminis- 
tered in the form of alkaline mineral water. The patient 
should observe absolute rest in bed. The bladder may be 
washed with dilute solutions of creolin. The salicylates and 
methylene-blue may be given to limit or prevent bacterial 
activity. Other remedies highly recommended are quinine, 
dilute h^Tlrochloric acid, creosote, turpentine, and the oils of 
copaiba and sandalwood. Sometimes resort must be made to 
nephrotomy or nephrectomy. 



NEPHR OLITHIASIS. 



373 



FLOATING KIDNEY (Wandering Kidney; Movable Kidney; 
Ren Mobile). 

Undue mobility of the kidney is caused by the presence of 
a mesonephrGu, undue laxity of the abdominal walls, more 
often by compression by belts, corsets, and still more fre- 
quently, probably, by traumatism, violent concussions of the 
body. 

Floating kidney — symptomatology : There may be no symp- 
toms. The patient sometimes complains of the symptoms of 
dyspepsia, which are not relieved by the usual treatment of 
dyspepsia. There may be pain, colic, abdominal dragging, 
sensations of displacement, sometimes icterus, and symptoms 
of the most varied character. A movable tumor may be felt 
upon palpation ; but the failure to find such a tumor does not 
necessarily exclude floating kidney. The kidney is usually 
sensitive. 

Prognosis as to life is good. As a rule permanent relief 
may be secured only by appeal to surgery. 

Treatment : Should satisfactory relief not be afforded bv 
the use of an abdominal supporter, n ephroiThaphy {hxsition of 
the kidney by suture) should be resorted to. Nephrectomy 
(removal of the kidney) may be necessary when the organ is 
diseased. 

NEPHROLITHIASIS ; KIDNEY-STONE (Renal Calculus ; Gravel ; 

Sand). 

Over 99 per cent, of all urinary calculi originate in the 
kidneys. Kidney-stones may consist of uric acid or urates, 
oxalate of lime, less frequently of cystin, carbonate of lime, 
xanthin, or indigo ; sometimes two or more of these sub- 
stances in combination ; and in the presence of suppuration, 
and decomposition of urine, there may be deposits of phos- 
phate of lime and triple phosphate. Kidney-stones occur 
in all varieties of shape, and in size from so-called sand to 
over a thousand grammes in weight ; and from one to over a 
thousand in number. 

Etiology : The great majority of cases occur in males, most 
frequently from tw^o to twelve years old. Association of 



374 DISEASES OF THE GENITO- URINARY ORGANS. 



kidney-stone with gout has been frequently noted. Cases are 
often ascribed to an excess of uric acid in the blood, or a 
diminution of the biphosphate of sodium, a salt that holds 
the uric acid in solution. Phosphates are precipitated in an 
alkaline urine, the result of decomposition. Nephrolithiasis 
may occur at any age ; calculi have been found in the kidneys 
of the new-born. 

Some observers believe a prominent role in etiology is 
played by the mucus and possibly some colloid material se- 
creted by the kidney. 

Symptomatology : There may be no symptoms. But usually 
the presence, especially the passage, of kidney-stones gives rise 
to distinct symptoms. The most common symptom is pain, 
radiating from the hidney to the bladder, aggravated by move- 
ment of the body, and usually increased by pressure over the 
kidney. The pain is irregular, occurs in paroxysms, and may 
be relieved only by large doses of opium or morphine or the 
use of amestliesia. There is usually hcematuria, often jyyuria, 
and sometimes albuminuria even independently of the presence 
of blood. The pain, especially during the ptussage of a cal- 
culus througli the ureter, is intense. With the paroxysm 
there are often rigor, vomiting, cramp, and profuse perspira- 
tion. Pain is often reflected to the groin, testicle, gluteal 
region, and inner side of the thigh and leg. Often there is 
retraction of the testicle. With the passage of the stone into 
the bladder the paroxysm suddenly ceases, possibly to leave 
the patient narcotized if much opium or morphine has been 
administered. The urine often contains mucus during the re- 
tention of a stone in the kidney. 

Diagnosis : Sometimes the patient comes with the diagnosis 
already made by the passage of a stone, more often of the 
small particles known as sand, or with the history of having 
passed a calculus. Such specimens should be examined to 
determine the character of the stone. 

The most common urinary calculi are the uric acid and phos- 
phatic stones. When there is no history of the passage of a 
calculus the characteristic pain, the presence of blood and 
mucus, sometimes of pus in the urine, should lead to a micro- 
scopic examination of the urine, whereby crystals may be 



XEPHB OLITHIASrS. 



375 



found, to reveal the presence and character of the stone. The 
condititjn sliuulJ luA be mistaken for the passage of uric acid 

Fig. 44. 




Yarious forms of uric-acid crystals (.Finlaysou). 
Pig. 45. 




Yarious forms of triple phosphate .Tinlayson). 



in gont. or of the debris from tubercular or cystic kidneys 
or hydatids of the kidney. 

Prognosis should be guarded. Recovery is the rule. The 



376 DISEASES OF THE GENITO-URINARY OBGANS. 



chief danger is rupture of the ureter and consequent peri- 
tonitis ; or the formation of abscesses, with sinuses and fis- 
tulse, and consequent marasmus ; and amyloid degeneration in 
the various organs. 

Kidney-stone — treatment: During the attack the pain shouki 
be relieved by moderate doses of morphine combined with 
atropine, round doses of chloral, the application of moist heat, 
and if necessary the use of an anaesthetic. 

Curative treatment consists in thorough flushing of the 
kidneys by free libations of fluids, the mineral waters — Sara- 
toga, Bethesda, Carlsbad, Contrexeville, Ems — and the lith- 
iated waters, barley-water, or pure water. Piperazin, gr. 
v-xv, may be given in soda or Seltzer Avater three to five 
times a day. Gentle massage is sometimes of value. Upon 
failure of these means an appeal must be made to surgery. 
Nephrolithotomy or, in the presence of extensive disease of 
the kidney, nephrectomy may be indicated. 

HYDRONEPHROSIS. 

Etiology : When the escape of urine is prevented, through 
occlusion of the pelvis of the kidney or ureter, the pelvis and 
calyces of the kidney undergo dilatation to form a retention- 
cyst. The cyst may vary from the size of a pea to an extreme 
size, in which the kidney-substance sufl'ers destruction from 
pressure and the cyst comes to occupy the entire capsule. The 
smaller cysts are caused by dilatation of the urinary tubules. 
The larger cysts, to which the name hydronephrosis is given, 
are due to occlusion of the pelvis of the kidney or ureter by 
calculi, strictures, cicatrices, and pressure from without, as 
from tumors of the uterus and ovaries, enlarged prostate, etc. 

Other causes are cancer, cystitis, and vesical calculus. Com- 
pression of the ureter of a movable kidney may be caused by 
the gravid uterus. Rarely cases are caused by traumatism. 
Some cases are due to congenital deformity. 

The retained fluid is usually composed of dilute urine, more 
or less albuminous ; occasionally colloid material ; sometimes 
blood and broken-down cells. The cysts may attain immense 
size. As much as thirty gallons have been removed (Glass). 



HYPEREMIA OF THE KIDNEY. 



377 



The loss of one kidney may be compensated for by the oppo- 
site organ. Implication of both kidneys is always dan- 
gerous. 

Treatment should address the cause. Sometimes appeal 
must be made to surgery : aspiration, nephrotomy, and drain- 
age ; possibly nephrectomy, 

HYPEREMIA OF THE KIDNEY. 

Hyperaemia may be acute or chronic, depending upon tem- 
porary or more or less permanent congestion of the blood- 
vessels of the kidney. 

Acute hypermmia of the kidney may be caused by : certain 
poisons — for instance, cantharides, either when ingested or 
sometimes when used as blisters or ointments ; the extirpation 
of the opposite kidney ; severe traumatism; surgical opera- 
tions, especially upon the bladder or urethra ; and over- 
exertion, forced marches, severe physical contests, and violent 
exercise. 

The most common causes of chronic hypercemia of the kid- 
ney are chronic inflammations involving the aortic and, mitral 
valves, dilatation of the heart, aneurism of the arch of the 
aoiia, pulmonary emphysema, and large accumulations of fluid 
in the pleural cavities that are not properly treated by re- 
moval. 

In acute hype7'cemia the urine is diminished in quantity, 
sometimes to constitute anuria ; the specific gravity remains 
about normal ; blood, albumin, and casts are present. In 
chronic hypercemia there is some diminution in the quantity 
of urine, and the specific gravity may be a little higher than 
normal ; there is little albumin, and there are but few or no 
hyaline casts ; there is often dropsy, usually with some symp- 
toms of affection of the heart. 

The treatment will depend upon the cause. Usually of 
most value is rest of the kidney, which implies rest of the 
body, best in bed, and address to the skin and alimentary 
canal. 

Ansemia of the kidney : In general anaemia the kidneys 



378 DISEASES OF THE GENITO-VRINARY ORGANS. 



may suffer a reduction in size. The quantity of urine excreted 
is less than normal. Chronic anaemia of the kidney is ob- 
served in arterio-sclerosis. 

AMYLOID DEGENERATION. 

Amyloid degeneration is most frequently recognized when 
the process involves the kidneys. Amyloid follows protracted 
suppuration in some part of the body, as a rule. Tubercu- 
losis and syphilis are frequent causes. 

Symptomatology and diagnosis : The patient voids an in- 
creased quantity of dear urine, as a rule of low specific gravity, 
containing various amounts of albumin, with some casts and 
ich ite co7'puscles. Rarely there may be dropsy, especially in the 
lower extremities, often associated with ascites, due to obstruc- 
tion of the portal vein from affection of the liver. Vomiting 
and diarrhoea are sometimes persistent. Amyloid matter may 
be found in the stools, from involvement of the intestiue. 
There may also be symptoms on the part of other organs liable 
to amyloid degeneration, especially the spleen and liver. 
Nervous symptoms are usually absent. 

Evidence of amyloid degeneration may be found on the part 
of other organs, especially the spleen, liver, and alimentary 
canal. A chronic suppuration may be recognized. 

Prognosis : Bad. Most may be accomplished by proper 
treatment of the cause of the amyloid degeneration, especially 
septicsemia, syphilis, tuberculosis, malaria. 

Treatment : Any chronic suppuration should receive proper 
attention. Pus should be evacuated. Of drugs, iodine has 
the best reputation, probably because of the etiological rela- 
tionship of syphilis. Gtt. x of the tincture, or of the ounce- 
to-the-ounce solution of the iodides, may be given in a wine- 
glassful of milk three times a day. Should digestion be 
impaired by iodine, the remedy may be substituted by hydro- 
chloric acid, nux vomica, condurango, or the aromatic tincture 
of rhubarb. 

Tuberculosis of the kidney : See Tuberculosis. 

Syphilis of the kidney : See Syphilis. 



NEPHRITIS. 



379 



NEPHRITIS; BRIGHT'S DISEASE. 

Etiology : Not clear. Some investigators believe the disease 
to be clue to micro-organisms ; others attribute it to toxins or 
chemical poisons. Probably both views are correct. Some 
cases are caused by ptomaines, toxalbumins, acetone (von 
Jaksch) ; and cases may be caused by uric acid, creatin, xan- 
thin, and also by cantharides and other poisons. InteTstitial 
nephritis has been produced experimentally, in the dog, by 
the subcutaneous injection of oxalic acid and oxamide (Ebstein 
and Xicolaier). 

Most cases of nephritis are attributed to the infections, in- 
cluding colds." Pregnancy often plays a prominent role. 

Classification of nephritis : After Pel, of Amsterdam, as 
given by ^Yhittaker : 



1 -Acute Nephritis 



2-Clironic Nephritis 



8-Renal Cirrhosis 




k 



General degenerative 
jarterio-sclei^osis 
(frequent) 



Chronic hemorrhagic Nephritis ^ 
(not frequent) 



Spotted or smooth small ichite 
or secondary shrunken kidney 
(very frequent) 



Genuine (inflammatory) 
Interstitial nephritis 
(most frequent) 



Three varieties of Bright's disease are generally accepted : 
acute nephritis, chronic nephritis, and renal cirrhosis. Be- 
sides these there are transition-forms, as indicated in the 
above table. 



Acute Parenchymatous Nephritis. 

Etiology : Acute parenchymatous nephritis is caused by the 
excretion of some poison through the kidneys. Typical acute 
inflammation of the kidney may be produced by cantharides. 
Acute parenchymatous nephritis is most frequently caused by 
toxins, toxalbumins, in the course of or following the infec- 



380 DISEASES OF THE GENITO-URINARY ORGANS. 



tious diseases, especially scarlet fever and diphtheria ; less 
frequently measles, rotheln, smallpox, pneumonia ; rarely 
typhoid fever and the other infections. Some cases are 
ascribed to ^^cold" and pregnancy. "Colds'' are usually 
infectious. 

Symptomatology : The onset may be sudden or insidious. 
Usually micturition is incy-eased in frequency, but the quantity 
of urine voided in tiventy-four hours is less than normal. There 
may even be anuria. With the reduction in quantity there is 
an increased specific gravity, 1025-1030. There may be 
hsematuria with consequent change in color of the urine. 
More characteristic is the presence of albumin, usually with 
epithelial and blood-casts. As a rule there is dropsy, observed 
first as a puffiness about the eyelids, sometimes extending to 
become general over the body, possibly to take life through 
oedema of the lungs or glottis. Prominent nervous symptoms 
are headache and neui^algia, vertigo, nausea and vomiting. 
Some cases are announced by sudden blindness or early con- 
vulsions. There may be sopor, stupor, and coma. 

Chronic Parenchymatous Nephritis. 

Etiology: Chronic parenchymatous nephritis is caused, for 
the most part, by the long-continued elimination of a poison, 
usually a toxin. Some cases result from acute parenchyma- 
tous nephritis, especially when due to septicsemia, syphilis, or 
tuberculosis ; sometimes when due to scarlatina, pregnancy, 
or " cold." 

Symptomatology : The onset is usually insidious, with loss 
of ambition, fatigue on slight exertion, sometimes with nervous 
symptoms, especially hebetude, headache, and neuralgia. There 
are anorexia, loss of weight, pallor, drowsiness or insomnia, 
palpitation, shortness of breath ; and dropsy, appearing first 
as oedema of the face, especially the eyelids ; and about the 
ankles, becoming later extensive and marked. There may 
be retinitis albwminurica. 

The urine is reduced in quantity, from two pints to a half 
pint or less in twenty-four hours, and is high in specific gravity, 
1025-1040, and cloudy. Albumin is present in large quantity, 



NEPHRITIS. 



381 



and casts may be found in large numbers and great variety. 
Broad, wa.vi/, and granular casts are characteristic. 

Voiiiitinrj and diarrhrca may become troublesome and per- 
sistent. The poison of the disease seems sometimes to become 
localized in an inlianiiaation of some serous me/nbrane, as a 
pleuritis, peritonitis, or pericarditis. Xervous symptoms may 
be present in all grades of severity. 

Renal Cirrhosis. 

Renal cirrhosis is the most frequent form of Bright's dis- 
ease, constituting more tlian one-half of all cases. The onset 
is insidious, so that the condition may be unrecognized for a 
number of years. Renal cirrhosis is characterized by the 
secretion of a large amount of urine, of light specific 
gravity ; the presence of nervous symptoms, and the absence 
of dropsy. 

Symptomatology : The onset of rerifd cirrhosis is insidious, 
with depression of sjjii'ifs and iniixiirm, i,f i,j InalfJi. The color 
is bad. Xervrjus st/mptouis jnu ihmiinjjff . There are often 
headache, neuralgia, vertigo. dy-piKfa (renal asthma), jja//j//a- 
tion of the heart, and sometimes blindness or other disturbance 
of vision. The first sus])icion of the disease may be aroused 
by the occurrence of apoplexy or hemorrhage, especially from 
the nose, stomach, or bowels. The patient voids a large 
qnarditji of cJedr urine, u'ith light specifir grarifif, 1010 or less. 
The urine contains little sediment. Upon examining a speci- 
men from the total quantity passed in twenty-four hours a 
trace of albumin will be found (see Spiegler's test). Casts are 
few and difficult to find. Usncdli/ there is no dropsy. En- 
largement of the heart is caused by liiipertrophy of the left 
rent ride, which becomes necessary to overcome the obstruction 
offered to the circulation through the kidneys. The strong 
heart continues for a long time to force a large quantity of 
fluid through the kidneys, and as long as this continues dropsy 
is absent. The urine, though passed in large quantities, con- 
tains little solid matter, so that symptoms of uraemia are not 
infrequent. 



382 DISEASES OF THE GEXITO-URINARY ORGANS. 



Diagnosis of Bright's Disease. 

Acute parenchymatous nephritis may come on suddenly or 
insidiously. There is a reduction in the quantity of urine, 
whichi is high in specific gravity and contains albumin and casts, 
especially epithelial and blood-casts. CEdema appears first 
about the eyelids. There may be headache, neuralgia, vertigo, 
convulsions, nausea and vomiting, sometimes sudden blindness. 

In the presence of the large white hidney there are marked 
pallor and obstinate dropsy, in the absence of hypertrophy of 
the heart. The urine is small in quantity, of high specific 
gravity, and contains casts, especially fatty and granular casts. 
Xervous symptoms are usually not pronounced. 

Chronic parenchymatous nephritis is usually insidious in 
onset, with general degradation of the health, spirits, and 
strength. Some cases show nervous symptoms. There is 
oedema, first of the face and ankles. A retinitis albuminurica 
may be observed. The urine is reduced in quantity, of high 
specific gravit}'. and contains albumin and casts, especially 
broad and Avaxy casts. There may be inflammation of the 
serosse. Often there are vomiting and diarrhoea. Xervous 
symptoms vary in severity. 

In hemorrhagic nephritis there is persistent bleeding. The 
course is longer than in acute nephritis, and the nervous 
symptoms are not so marked. 

Cases of the small vhite kidney show enlargement of the 
heart, and reduced quantity of urine containing casts of all 
kinds. Transition from the large white kidney, or chronic 
hemorrhagic nephritis, to the small white kidney is marked by 
an increase in the quantity of urine and diminution in the 
number of casts, with hypertrophy of the heart. 

Renal cirrhosis, the most frequent form of Briglit's disease, 
begins insidiously. Nervous symptoms are marked. CEdema 
is slight or absent. A large quantity of urine is voided, of 
light specific gravity, containing a trace of albumin and pos- 
sibly a few hyaline casts. There are hypertrophy of the 
heart and the sym])t()ms of arterio-sclerosis. Blindness may 
be caused by retinitis albuminurica. The patients are usually 
in middle or advanced life. 



NEPHRITIS. 



383 



Prognosis of Bright's Disease. 

Acute nephritis may result in recovery. Anuria, hsema- 
turia, and severe nervous symptoms, especially convulsions 
and coma, are ominous signs. Much depends upon the time 
when proper treatment is instituted. 

Cases of chronic nephritis or renal cirrhosis probably never 
recover, but the patients may live for a long time under proper 
treatment and hygiene. 

Treatment of Bright's Disease. 

The best single article of diet is milk, which may be used 
exclusively in severe cases. Later, vegetables and fruit may 
be added. The patient should drink an abundance of pure 
water; but an undue amount of fluid must not be given in 
the presence of a weak heart. Meat may be given, but not 
to excess : The patient may receive stewed sweetbreads, 
stewed chicken, calf-brains, pig's feet, or broiled fish once a 
day. 

Bathing: A hot bath, 100°-110° F., may be given at bed- 
time, and in severe cases oftener. Duration of bath, five to 
twenty minutes. A hot drink should be given before and 
after the bath. While in the bath the patient's head should 
be enveloped in a cloth wrung out of cold water. Sometimes 
it is necessary to substitute the hot bath by the hot pack. 
Palpitation and a fluttering heart are contraindications to the 
hot bath. In such cases pilocarpine may be used, gr. j^-i, 
subcutaneously. 

Drugs : Pilocarpine has been recommended externally, in 
the form of an ointment, 0.05-0.1 to 10.0 of vaseline (Mol- 
liere). The use of pilocarpine is contraindicated by uraemia. 

Cardiac diuretics, usually contraindicated in acute paren- 
chymatous nephritis, are often of service in chronic nephritis 
and 7'enal cirrhosis. The best diuretic is digitalis, which at 
times may be substituted by strophanthus, sodium-benzoate 
of caffeine, diuretin, or nitroglycerin, which is the best agent 
with which to secure immediate results in the presence of 
cirrhosis, 



384 DISEASES OF THE GENITO- URINARY ORGANS. 



Dropsy that causes dyspnoea or other great discomfort, or 
that threatens rupture of the skin, may be relieved by the free 
use of calomel or a dose or two of elaterin ; or by the intro- 
duction of silver canulse into the feet or legs, or by minute 
punctures of the skin. 

Often a change of residence to a warm, dry climate is 
advisable. The patient should wear warm clothing and 
remain indoors during inclement weather. 

Further treatment is addressed to the 7'elief of symptoms. 

CYSTITIS. 

Etiology : Cystitis is caused most frequently by extension 
of disease from the urethra, especially gonorrhoea. Next most 
frequently, the cause of cystitis comes from above, especially 
from pyelitis and calculus. 

Tuberculosis and cancer may be conveyed to the bladder 
through the blood or lymph-vessels, or by extension from 
contiguous structures, especially from the uterus and rectum. 

Infection of the bladder may occur as a local expression of 
septicaemia. Paralysis of the bladder, by permitting reten- 
tion, may favor infection of the bladder. Sometimes trauma, 
especially the introduction of foreign material into the blad- 
der, plays an important part in tlie etiology of cystitis. In 
operations upon the bladder, the use of the catheter and the 
introduction of the cystoscope or instruments for crushing 
and removing stones, strict asepsis should be observed. 
Stricture of the urethra, or any cause of retention of urine, is 
a prominent cause of cystitis. 

Cystitis — symptomatology : There are pain in the region of 
the bladder, tenderness, vesical and rectal tenesmus, frequent 
and painful micturition. The urine contains jms, mucus, fre- 
quently blood, and usually large numbers of the characteristic 
flat epithelial cells found normally in the bladder. The pain 
is often reflected to the penis, testicles, and rectum. In tuber- 
culosis of the bladder there is often polyuria. When cystitis 
is due to the prcvsence of a calculus in the bladder, there is 
often hemorrhage, and pain is increased by movement of the 
body. 



ENURESIS. 



385 



Prophylaxis : Only clean instruments should be introduced 
into the bladder. This applies equally to the use of the 
catheter, cystoscope, and instruments for crushing stones. 
Urethritis, especially gonorrhoea, should receive early and 
continuous treatment until completely cured. Strictures 
should be dilated and stones removed. 

Cystitis — treatment : Rest in bed is important. The diet 
should be light. The bowels must be kept open. The 
bladder may be flushed by the free use of hot drinks, milk, 
mucilaginous drinks. Harrison recommends a combination 
of the ulmus fulva, or slippery elm, and succus hyoscyami in 
decoction. Hyoscyamin may be given, gtt. iij-v of the grain- 
to-the- ounce solution, every three or four hours. Atropine 
is administered in the same dosage. 

Great relief is often afforded by the warm bath, and the 
rectal injection of hot water. More severe pain calls for 
opium in suppositories or by rectal injection. Strangury may 
be relieved by the subcutaneous use of morphine, preferably 
suprapubic, in the region of the bladder. 

Cystitis due to gonorrhaa is benefited by the internal use of 
copaiba, the oil of yellow sandalwood, salol, the salicylate of 
sodium, and methylene-blue. 

Chronic cases of cystitis are best treated by irrigation of 
the bladder. For this purpose use may be made of solutions 
of nitrate of silver ; protargol ; creolin ; boric acid ; bichloride 
of mercury (1: 20,000) ; permanganate of potassium ; tannin ; 
sulphate of zinc ; alum ; alumnol, or the neutral sulphate of 
quinine (gr. j to ,^j). 

ENURESIS (Incontinence of Urine). 

The involuntary discharge of urine occurs normally in in- 
fancy. Sometimes delayed development of the sphincter, 
especially of its nerve-supply, causes persistence of enuresis. 
Thus the condition is seen frequently from three to ten years 
of age, especially during sleep. 

As a neurosis, enuresis occurs in the presence of a normal 
bladder and normal urine. At times the condition appears 
at puberty, often with other neuroses, sometimes onanism. 

25.— P. M. 



386 DISEASES OF THE GENITO-UBINARY ORGANS. 



Inability to retain the urine — incontinence of urine — oc- 
curs most frequently in the young and old ; in Avomen more 
often than in men. In women the urethra may suffer dilata- 
tion and the action of the sphincter be imperfect, especially 
after parturition^ so that urine may be discharged with no, 
or but slight strain, such as coughing, sneezing, laughing. 

Enuresis may be caused by masturbation. Men, especially 
in old age, suiier incontinence of urine through affection of 
the prostate. 

Incontinence of urine is caused by over distention of the 
bladder, or by defective closure of the sphincter. Thus, the 
condition may be caused by either paresis of the detrusor or 
of the sphincter. Sometimes incontinence of urine results 
from organic disease. 

Treatment : An overdistended bladder should be relieved 
with a clean catheter. Urethral polypi and calculi should be 
removed. Often much may be accomplished with electricity, 
particularly ^vhen the current is brought into contact with 
the sphincter by introducing the electrode into the rectum. 
The best drug is atropine, gtt. iij of the grain-to-the-ounce 
solution at bedtime, increased gradually up to tolerance. 

In the way of general treatment, cold baths, outdoor exer- 
cise, and the use of iron, quinine, and cod-liver oil are of 
value. 

SPERMATOERHCEA. 

The involuntary discharge of semen may occur physiologi- 
cally once or twice a month. The condition is pathological, 
only when the discharge is followed by exhaustion. But not 
every discharge of fluid, even when followed by exhaustion, is 
a spermatorrhoea. The fluid may not be semen. Thus the 
condition may be a prostatorrh(sa. 

Etiology : The most frequent causes of spermatorrhoea are 
masturbation, sexual excess ; urethritis, especially gonorrhoea ; 
an elongated prepuce, phimosis ; ascarides, constipation, hem- 
orrhoids, eczematous eruptions, and abnormal conditions of 
the rectum and anus. 

Symptomatology : Sometimes the patient is not aware of the 
loss of semen, which is discharged with the urine, possibly to 



IMPOTENCE. 



387 



be recognized as a cloudiness of the urine and the discovery 
of spermatozoa upon microscopic examination. But sperma- 
tozoids are not always present in semen ; they may be absent 
in impotence. 

Following a pathological discharge of semen there are ex- 
haustion, a feeling of weakness, languor, and depression, and 
various nervous disturbances, par cesthes ice, flashes of heat, head- 
ache, and vertigo. Later there are palpitcdion, dyspncea, and 
dyspepsia. Depending usually upon sexual abuse, there is as 
a rule more or less hypochondriasis and melancholia. 

Diagnosis : In the presence of an exhausting discharge, the 
clinician should determine whether or not the discharge is 
semen. A simple prostatorrhoea will not contain spermato- 
zoids. Sometimes the discharge of semen takes place with 
urination, when the spermatozoids may be found in the urine. 

Treatment : Sexual abuse should be slopped. The sexual 
function had better be given a rest and the mind occupied 
with healthy thought and the body with healthful exercise. 
The cold bath or cold douche invigorates the body. Elec- 
tricity is sometimes of value : short sessions of feeble gal- 
vanic or fa radio currents. 

Posterior urethritis should l,e properly treated. Matrimony 
may be advisable, when other treatment, as a rule, becomes 
unnecessary. The discharge of semen, which usually occurs 
at night, may be prevented by potassium bromide, gr. xx-xl, 
largely diluted, at bedtime. 

IMPOTENCE. 

Incapacity for natural coitus may result from lack of sexual 
desire, absent or imperfect erection, premature discharge and 
alterations, especially reduction or absence, of the seminal 
fluid, and the absence of living spermatozoids. 

Impotence is caused most frequently by excess in venery, 
onanism, and gonorrhoea. The condition occurs early in dia- 
betes, di])htheria, and locomotor ataxia. Aversion, dislike, 
and the fear of loss of the sexual power are prominent physi- 
cal causes. Toxic causes are alcohol, the bromides, iodides, 
opium, camphor, salicylic acid, and lupulin. The condition 



388 DISEASES OF THE GENITO URINARY ORGANS. 



may be caused by physical malformations and defects, atrophy, 
and tumors. Undescended testicles cause impotence only 
when atrophied. 

The prognosis depends upon the cause, and is usually most 
favorable in the toxic and psychical cases. 

Treatment : The cause must be removed. Rest and ab- 
stention are important. The best remedies, as a rule, are 
strychnine and electricity. 



INDEX. 



Abscess of the liver, 238 

of the lungs, 283 
Achylia gastrica, 202 
Actinomyces, 132 
Actinomycosis, 132 

diagnosis, 133 

etiology, 132 

symptoms, 132 

treatment, 133 
Acute infectious icterus, 125 
Addison's disease, 347 
symptoms, 347 
treatment, 348 
Ague, 134 
Akoria, 204 
Albumin, tests for, 365 
Heller's, 365 

potassium-ferrocyanide, 365 
Spiegler's, 365 
Albuminuria, 364 
accidental, 364 
etiology, 364 
Amoebi coli, 142 
Amphistoma, 156 
Amygdalitis, 176-178 
Amyloid degeneration, 378 

liver, 245 
Ansemia, 336 
pernicious, 337 
primary, 336 
secondary, 336, 339 
blood in, 338 
symptoms, 338 
treatment, 339 
Aneurism, 329 
varieties (see also Bloodvessels, dis- 
eases of), 329, 330 
Angina, 176 
Ankylostomiasis, 161 
Anorexia, 204 
Anthracosis, 284 
Anthrax, 115 
bacillus, 115 



Anthrax, external, 116 
forms, 116 

anthrax oedema, 116 
external anthrax. 116 
internal anthrax, 116 
malignant pustule, 116 
internal, 116 
intestinal, 117 
oedema, 116 
pulmonary, 116 
symptomatology, 116 
treatment, 117 
caustics, 117 
cautery, 117 
serum, 117 
Antitoxin in diphtheria, 67 
Aortitis, 326 
Aphtha, 171 

Bednar's, 172 
Appendicitis, 217 
chronic, 218 
diagnosis, 218 
etiology, 217 
prognosis, 218 
symptoms, 217 
duluess, 217 
pain, 217 
treatment, 219 
diet, 219 
operation, 219 
rest, 219 
Arterio-sclerosis, 327 
Arthritis deformans, 352 
etiology, 352 
symptoms, 352 
treatment, 352 
Ascaris lumbricoides, 157 

other varieties, 159 
Asthma, 269 
etiology, 269 
symptoms, 270 

spirals, 271 
treatment, 272 
of the attack, 272 
cigarettes, 272 

389 



390 



INDEX. 



Asthma, treatment during intervals, 
272 
arsenic, 272 
iodides, 272 
Atelectasis, 282 
symptoms, 282 
treatment, 282 
Atheroma, 306, 328 
aorta, 328 

coronary arteries, 328 
Atrophy of the heart, 297 
liver,' 243 
acute, 243 
simple, 243 
yellow, 243 
Autumnal catarrh, 130 

B. 

Bacillus anthracis, 115 
coli communis, 142 
icteroides, 107 
pestis, 124 
prodigiosus, 171 
of tetanus, 118 

tuberculosis,carbol-fuchsin solution, 
74 

examination, 73 
tuberculin test, 74 
typhosus, 93, 98 
Beri-beri, 128 
etiology, 128 
symptoms, 128 
treatment, 129 
Big-jaw, 132 
Biliary lithiasis, 233 
Blood, diseases of, 335-355 
parasitic, 335 
blood-corpuscles, 335 
red, 335 
white, 335 
Bloodvessels, diseases of, 326-334 
aneurism, 329 
dissecting, 330 
external, 329 
internal, 330 
miliary, 330 
aortitis, 326 
arteritis, 326 
arterio-sclerosis, 327 
embolism, 332 
phlebitis, 333 
thrombosis, 331 
yarices, 334 
Bothriocephalus latus, 153 
other species, 153 



Break-bone fever, 123 
Bright's disease (see also Nephritis), 
379 

Bronchi, dilatation, 268 

diseases of, 261-273 
Bronchiectasis, 268 
etiology, 268 
symptoms, 268 
treatment, 269 
Bronchitis, 262 
acute, 262 
etiology, 262 
symptoms, 263 
treatment, 263 
capillary, 264 
chronic, 264 
etiology, 264 
symptoms, 265 
treatment, 265 
fibrinous, 267 
plastic, 267 
etiology, 267 
sym]Dtoms, 267 
treatment, 268 
Bronze-skin disease, 347 
Buboes, 89 

c. 

Csecitis, 215 
Calculus, renal, 373 
Cancer of the stomach, 196 
Cancrum oris, 172 
Carbnncle, 115 

Carcinoma of the intestine, 225 
of the larynx, 259 
of the peritoneum, 230 
Cardiospasmus, 205 
Casts, 365-368 
blood, 366 
epithelial, 365 
fatty, 368 
granular, 367 
hyaline, 368 
micrococci, 367 
pus, 367 
waxy, 368 
Cerebro-spinal meningitis, 26 
complications, 27 
diagnosis, 28 
etiology, 26 
forms, 27 
abortive, 27 
apoplectic, 27 
chronic, 27 
foudroyant, 27 



INDEX. 



391 



Cerebro-spinal meningitis, forms, ful- 
minant, 27 
intermittent, 27 
malignant, 27 
history, 26 
morbid anatomy, 27 
prognosis, 28 
symptomatology, 26 
blood, 27 
eruptions, 27 
incubation, 26 
treatment, 28 
diet, 28 
hot bottles, 29 
ice-bags, 29 
laminectomy, 29 
lumbar puncture, 29 
opium, 28 
Cestodes, 145 
Chalicosis, 284 
Chancroid, 86 

Chickenpox (see also Varicella), 63 
Chills and fever, 134 
Chlorosis, 336 
Egyptian, 161 
tropical, 161 
Cholelithiasis, 233 
Cholera, 110 
Asiatic, 110 
definition, 110 
diagnosis, 111 

bacteriological examination, 111 
blood-test, 112 
etiology, 110 

spirillum cholerse, 110 
history, 110 
prognosis, 112 
prophylaxis, 112 

quarantine, 112 
symptomatology. 111 
incubation. 111 
onset, 111 
stools. 111 
treatment, 112 
anticholerin, 112 
antitoxin, 112 
infusion, 113 
intestinal irrigation, 113 
opium, 113 
warm bath, 113 
gravis, 111 
infantum, 113 
morbus, 113 
nostras, 113 
true, 110 
Cholerine, 111 



Chyluria, 370 

Cirrhosis of the liver, 240 

hypertrophic, 242 

renal (see also Renal cirrhosis), 381 
Clap, 86 
Colitis, 208 

Corpulence (see also Obesity), 355 
Cow pox, 61 
Croup, 69 

false, 69 

true, 69 
Cylindroids, 368 
Cysticercus acanthotrias, 151 

cellulosse, 151 
Cystitis, 384 

etiology, 384 

prophylaxis, 385 

symptoms, 384 

treatment, 385 

I>. 

Degeneration, amyloid, 378 
Dengue, 123 
diagnosis, 123 
etiology, 123 
symptoms, 123 
treatment, 124 
Diabetes, acute, 360 
insipidus, 362 
symptoms, 362 
treatment, 362 
mellitus, 356 
etiology, 356 
history, 356 
symptoms, 357 
treatment, 360 
diet-list, 360, 361 
drugs, 361 
Diarrhoea, choleraic. 111 
Diathesis, hemorrhagic, 343 

uric-acid, 348 
Dilatation of heart, 297 

of stomach, 199 
Diphtheria, 64 
complications, 65 
diagnosis, 65 

bacteriological examination, 65, 66 
media, 66 

pseudo-diphtheria bacillus, 65 

false membrane, 65 
etiology, 64 

bacillus diphtherise, 64 
history, 64 
membrane in, 64 
prophylaxis, 67 



392 



INDEX. 



Diphtheria, prophylaxis, antitoxin, 67 
isolation, 67 
symptomatology, 64 

laryngeal diphtheria, 65 
nasal diphtheria, 65 
pharyngeal diphtheria, 64 
treatment, 67 
antitoxin, 67 
local applications, 68 
steam, 68 
Distoma, 154 

haematobium, 156 
hepaticum, 154 
other varieties, 155-157 
Distomiasis, 154-156 
Downward displacement of the stom- 
ach, 200 
Dracontiasis, 163 
Dropsy, 368 
Dysentery, 142 
etiology, 142 
prophylaxis, 144 

drinking-water, 144 
sequelfB, 143 
symptoms, 143 
treatment, 144 
castor-oil, 144 
diet, 145 

irrigation of colon, 144 
Dyspepsia, nervous, 207 

E. 

Elephantiasis grsecorum (see also Lep- 
rosy), 78 
Embolism, 332 
Emphysema, 280 
interstitial, 280 
pulmonary, 280 
symptoms, 280 
treatment, 281 
vesicular, 280 
Empyema (see also Pleurisy), 287 
Endocarditis, 303 
acute, 303 
etiology, 303 
physical signs, 305 
symptoms, 304 
treatment, 306 
chronic, 306 
etiology, 306 
symptoms, 307 

remote, 307 
treatment, 308 
sclerotic, 306 
septic, 303 



Enteric fever, 92 
Enteritis, 208 
Entero-colitis, 208 
acute, 208 
chronic, 209 
diagnosis, 210 

burns of skin, 210 
indican in urine, 210 
symptoms, 209 
treatment, 211 
antisepsis, 211 
boiled water, 212 
diet, 211 
drugs, 211 
irrigation, 211 
Enteroptosis, 223 
Enterorrhagia, 213 
collapse, 214 
diagnosis, 214 
etiology, 213 
hsematemesis, 214 
symptoms, 214 
Enuresis, 385 

treatment, 386 
Eructation, 206 
Erysipelas, 22 
complications, 24 

mixed infection, 24 
diagnosis, 24 
etiology, 22 
history, 22 
prognosis, 25 
symptomatology, 23 
eruption, 23 
incubation, 23 
cedema, 24 
treatment, 25 
local, 25 

serum-therapy, 26 
varieties, 23 
erratic, 23 

erysipelas migrans, 23 
multiple, 23 

F. 

Farcy, 89, 90 
Fatty liver, 244 

degeneration, 244 

infiltration, 244 
Filaria sanguinis hominis, 370 
Filariasis, 164 
Flukes, 154 
Flux, 142 
Fomites, 23 

Foot-and-mouth disease, 91 



IXDEX. 



393 



Foot-and-mouth disease, symptomatol- 
ogy, ta 
treatment, 92 

G. 

Gall-stones, 233 
constituents. 233 
bile-pigment. 233 
cholesterin, 233 
salts. 233 
etiology. 234 
goat. 234 
rheumatism. 234 
symptoms. 234 
treatment. 235 
glycerin. 235 
morphine. 235 
olive-uil. 235 
surgery. 235 
Gastraigia. 2u4 
Gastrectasia, 199 
Gastric catarrh. 157 
acute, 157 
etiology. 157 
symptoms. 157 
toxic cases. 157 
treatment. 155 
chronic, 159 
diagnosis, 190 
etiology, 159 
symptoms. 190 
treatment. 191 
diet. 191 
druss. 192 
electricity. 191 
enernata. 192 
mineral waters, 191 
carcinoma. 196 
diasnosis. 195 

absence of HCl, 193 
cachexia. 195 

pain, 195 | 
presence of lactic acid, 193 \ 
tumor, 195 I 

etiolosv. 196 j 
spr.rozoa, 196 I 

symptoms. 197 [ 

treatment. 199 ' 
chloral. 199 \ 
iodides, 199 i 
opium. 199 I 
resection of pylorus, 199 j 
^vashing the stomach, 199 

varieties. 197 j 
colloid. 197 1 



Gastric carcinoma, varieties; epithe- 
lial, 197 
medullary, 197 
melanotic, 197 
scirrlious, 197 
hyperttstliesia, 204 
ulcer. 193 
etiology. 193 
infaVct, 193 
injuries, 193 
vegetable diet, 193 
symptoms. 194 

hyperchlorhydria, 194 
nausea. 194 
vomiting, 194 
treatment, 195 
milk. 195 

rectal alimentation, 195 
rest. 195 
Gastroptosis. 200 
Gastrusuccijrrhcea, 202 
Glanders. -9 
chronic. 90 
symptomatology, 90 
treatment, 90 
Glandular fever. 129 
diagnosis. 130 
symptoms, 129 
Glossitis. 175 
acute. 175 
chronic, 175 
Glycosuria. 356 
Gonococcus. 57, 88 
examination, 83 
Gonorrhrea. 56 
complications, 87 
diagnosis. 57 
etiology. 56 

gonococcus, 87 
symptomatology, 87 
treatnient. 58 
bowels, 53 
copaiba. S3 
diet, 55 
local. 59 

lead acetate. 59 
protargol, 59 
silver nitrate. 59 
posterior urethritis, 89 
priapism. 55 
rest. 83 

sandalwood, 89 
Gout. 349 

American, 343 
symptoms, 350 
' tophi, 350 



394 



INDEX. 



Gout, symptoms, uric acid, 350 
treatment, 351 

alkaline mineral waters, 351 

colchicum, 351 

diet, 351 
Gravel, 373 

Grip (see also Influenza)^ 34 



H. 

Hsematidrosis, 344 
Hsematuria, 370 
etiology, 370 

diseases of bladder, 370 
kidney, 370 
prostate, 370 
ureter, 370 
urethra, 370 
distoma haematobium, 370 
drugs, 370 

infectious diseases, 370 
Hsemocytozoon, 134 
Hsemophilia, 345 
etiology, 345 

through mother, 345 
symptoms, 345 
treatment, 346 
Hay-asthma, 130 
-fever, 130 
etiology, 130 
occurrence, 130 
symptoms, 130 
treatment, 131 
Heart atrophy, 297 
dilatation, 297 
symptoms, 299 
treatment, 300 
diseases of, 296 
hypertrophv, 297 
etiology, 298 
treatment, 301 
inflammations, 301-320 
neuroses, 320-326 
allorrhythmia, 321 
angina pectoris, 324 
etiology, 324 
symptoms, 324 
treatment, 325 
arrhythmia. 321 
bradycardia, 324 
permanent, 324 
temporary, 324 
delirium cordis, 321 
palpitation, 322 
pseudo-angina, 325 



Heart neuroses, pseudo-angina, etiol- 
ogy, 325 
symptoms, 326 
treatment, 326 
pulsus alterans, 321 
bigeminus, 321 
paradoxus, 321 
trigeminus, 321 
tachycardia, 323 

etiology, 323 
tremor cordis, 321 
valvular disease (see also Valvular 
disease), 306, 308 
Hemorrhagic diathesis, 343 
Hemorrhoids, 224 
Hepatitis, 238-241 

chronic interstitial, 240 
suppurative, 238 
Hodgkin's disease, 342 
Hydatid cysts, 149 
booklets, 150 
of the peritoneum, 230 
Hvdronephrosis, 376 

fluid in, 376 
Hydrophobia, 121 
diagnosis, 122 
prophylaxis, 122 

Pasteur treatment, 122 
sj^mptoms, 121 
incubation, 121 
stages, 121 

excitement, 121 
paralytic, 121 
premonitory, 121 
treatment, 122 
Hydrothorax, 289 
symptoms, 289 
treatment, 290 
Hyperemia of liver, 236-237 
active, 236 
passive, 237 
tropical, 237 
Hyperanakinesis, 206 
Hyperchlorhydria, 201 
Hyperorexia, 203 
Hypertrophy of the heart, 297 
Hyponakinesis, 206 

I. 

Icterus, 231 

acute febrile, 125 

infectious, 125 
diagnosis, 232 

Gmelin's test, 232 

Marechal's test, 232 



ISBEX. 



395 



Icterus, diagnosis. Petteukofer's test, 
232 
gravis, 243 
trearmeut, 233 
Ileus. 219 
Impotence. 357 
Infecrion. 17 

seciiudary. IS 
Influenza. 31 
bacillus. 35 
definition. 34: 
diagnosis. 36 
etiology. 35 
history. 34 
prophylaxis. 36 
symptomatology, 35 
treatment. 36 
Insufliciency, 30S-314 
aortic, 3li 
mitral. 30S 
pulmonary. 314 
tricuspid. 313 
Intermittent fever. 134 
Intestinal catarrh. 20S 
hemorrluige, 213 
neoplasms. 225 
adenomata. 226 
angiomata. 226 
carcinouia. 225 
fibromata. 226 
lipomata. 226 
lymphosarcoma, 226 
myoiuata. 226 
myxomata. 226 
papillomata, 226 
polypi. 226 
sarcoma. 226 
obstruction. 219 
diagnosis. 222 

rectal examination, 222 
etiology. 219 

constipation. 220 
intas5usce]ition. 220 
stransulatinn. 220 
stricture. 220 
tumors. 220 
volvulus. 220 
symptoms. 221 
constipation, 221 
meteorism. 221 
pain, 221 
vomiting. 221 
treatment. 222 

air into bowel, 223 
colotomy. 223 
enterostomy, 223 



Intestinal obstruction, treatment, irri- 
gation, 223 
lava-e. 223 
liuru.in\-i--, 223 
Intestine-, ili^ea-es of, 203-226 
hemorrhage, 213 
ulcer, 212 

tubercular, 212 
typhoid, 212 

J. 

Jaundice, 231 

K. 

Kidney, amyloid degeneration, 378 
antemia, 377 
floating, 373 

sy Ml plums. 373 

treatment. 373 
hyperLT-niia, 377 

acute. 377 

chronic, 377 
movable, 373 

nephritis (see also Xe2)hritis\ 379 
stone in, 373 
syphilis of. 376 
tuberculosis of. 373 
T^'hite. 379 

lar^re, 379. 3-2 

small, 379. :;-2 
Kidney-stone, 373 
plirisphatic. 375 
syinritMius. 374 
tr.-arnient. 376 
uric-acid, 375 
varieties. 373 

L. 

Laryngitis. 254-256 
catarrhal. 254-256 

acute. 254 

chronic. 255 
Larynx, diseases of. 254-261 

benign tumors. 261 

carcinoma, 259 

neuroses. 261 

oedema. 256 

perichondritis. 257 

sarcoma. 260 

syphilis. 253 

tuberculosis, 253 
Leprosy. 73 
definition, 78 



396 



INDEX. 



Lepros}^, diagnosis, 80 
etiology, 79 

bacillus leprae, 79 
history, 78 
prognosis, 80 
symptomatology, 79 
anjesthesia, 79 
eruptions, 79 
nodules, 79 
treatment, 80 

chaulmoogra oil, 80 
gurgun oil, 80 
serum, 80 
Leukaemia, 341 
blood in, 342 
lymphatic, 341 
splenic-myelogenous, 341 
symptoms, 341 
treatment, 342 
Leukocythaemia(seealsoXeMfca3mia),341 
Leukocytosis, 340 
absence of, 340 
occurrence, 340 
abnormal, 340 
normal, 340 
Lichen tubercle, 71 
Lingua geographica, 175 
Lithaemia, 348 
definition, 348 
etiology, 349 
symptoms, 349 
treatment, 349 
Liver, abscess of, 238 
chronic, 239 
• subacute, 239 
symptoms, 238 
treatment, 239 
amyloid, 245 
atrophy, 243 
acute, 243 
simple, 243 
cirrhosis of, 240 
etiology, 240 
hypertrophic, 242 
symptoms, 240 
ascites, 240 
caput Medusae, 241 
treatment, 242 
diseases of, 231-247 
fatty, 244 

degeneration, 244 
infiltration, 244 
hyperaemia, 236 
active, 236 

symptoms, 236 
treatment, 237 



Liver, hyperaemia, passive, 237 
causes, 237 
symptoms, 237 
treatment, 238 
tropical, 236 
neoplasms, 246 

varieties, 246, 247 
tropical abscess of, 238 
Lockjaw, 118 
Lues (see also Syphilis), 81 
Lungs, diseases of, 273-285 
abscess, 283 
actinomycosis, 285 
echinococcus, 285 
gangrene, 283 

inflammation (see Pneumonia). 
oedema, 282 
syphilis, 285 



M. 

Macroglossia, 175 
Malaria, 134 
etiology, 134 

parasite, 134 
history, 134 
mosquito in, 187 
pernicious, 140 
prognosis, 140 
prophylaxis, 140 
symptoms, 137 
quartan, 137 
tertian, 137 
temperature-curve, 136 
treatment, 141 
arsenic, 142 
quinine, 141 
Malignant pustule, 115, 116 
Mallein, 90 
Malta fever, 126 
Marsh fever, 134 
Measles, 44 
definition, 44 
diagnosis, 47 

Koplik's spots, 47 
long prodi'oma, 47 
photophobia, 47 
etiology, 44 

protozoa, 44 
forms, 46 
rubeola afebrilis, 46 
nigra, 46 
siderans, 46 
sine catarrho, 46 
eruptione, 46 



IXBEX. 



397 



ileasles. French, (see also BubeUa), 49 
Grennan ( see also BubeLla), 49 
prognosis, 47 
prophylaxis, 47 
symptoms, 45 
desquamation, 46 
eruption, 45, 46 
exanthem, 45 
incubation, 45 
invasion, 45 
treatment. 43 
serum. 45 
ilediastinum, diseases o:^ 334 
Mediterranean fever, 126 
Meningitis, cerebro-spinal (see also 
Cerebrospinal meningitis), epi- 
demic, 26 
Miasmatic fever, 134 
Micrococcus pnemnoni* crouposse, 
273 

Miliary fever, 127 
Morbilli ( see also Measles), 44 
Mouth, diseases of. 168-174 

dry, ISO 

parasites, 174 
Mumps, 41 

definition, 41 

diagnosis, 43 

etiology, 42 

Steno's duct, 42 

history, 42 

prophylaxis, 43 

symptomatology, 42 
breast, 43 
incubation, 42 
parotid gland, 42 
testicle, 43 

treatment, 43 
Myalgia, 33 
Myocarditis, 301 

acute, 302 

chronic, 302 

etiology, 301 

symptoms, 302 

treatment, 302 

X. 

Neapolitan fever, 126 
Nematodes, 157 

Neoplasms of the liver, 246, 247 
Nephritis, 379-3S3 

acute parenchymatous, 379 
diagnosis, 3S2 
prognosis, 383 
clixonic parenchymatous, 380 



Nephritis, chronic parenchymatous, 

diagnosis, 352 
prognosis, 3^3 
classification, 379 
hemorrhagic. 379, 3S2 
iaterstitial, 379, 351 
treatment, 353 
bathing, 363 
change of residence, 384 
diet, 353 
of dropsy. 354 
drugs. 3^3 
Nephrolithiasis, 373 
Nervous dyspepsia. 207 
Neuroses of heart, 320-326 
jNoma, 172 

Nose, diseases of. 250-254 
acute catarrh. 250 
chronic catarrh. 252 
new growths, 253 

adenoids, 254 

polypi, 253 
syphilitic catarrh, 253 

o. 

Obesity, 355 
treatment, 355 
dietaries, 355 
Banting. 355 
Ebstein, 355 
CEdema of the larynx, 256 

of the lungs, 282 
CEsophagism, 186 
CEsophagitis, 155 
CEsophagoscope. 152 
(Esophagus, dilatation of, 183 
diseases of, 151-157 
diverticulum, 153 
hemorrhage, 184 
inflammations, 185 
obstruction. 182 

congenital stenosis, 182 
external compression, 182 
foreign bodies, 182 
strictures, 182 
tumors, 182 
perforation. 154 
Eontgen ray, 182 
rupture. 184 
spasm, 156 
tuberculosis, 185 
tumors, 186 
carcinoma, 186 
Oidium albicans, 173 
Osteomalacia. 354 
Oxyuris vermicularis, 159 



398 



I^'DEX. 



p. 

Pancreas, calculi, 249 

cysts, 248 

diseases of, 247-249 
hemorrhage, 247 
symptoms, 248 
treatment, 248 
tumors, 248 
Paratyphlitis, 215, 216 
Parorexia, 203 
Parotitis, 41, 180 
secondary, 180 
Peptonuria, 365 
Pericardial effusions, 296 
Pericarditis, 293 
acute, 293 
chronic, 293 
etiology, 293 
physical signs, 294 
primary, 293 
purulent, 296 

treatment, 296 
secondary, 293 
symptoms, 293 
treatment, 295 
Pericardium, 296 
diseases of, 293-296 
effusions, 296 
heenio-, 296 
hydro-, 296 
pneumo-, 296 
pyo-, 296 
inflammation (see Pericarditis). 
Peritoneal neoplasm, 230 
carcinoma, 230 
hydatid cysts, 230 
other varieties, 231 
Peritonitis, 227 
acute, 227 

complications, 228 
etiology, 227 
symptoms, 227 
treatment, 228 
laparotomy, 228 
opium, 228 
chronic, 230 
etiology, 230 
symptoms, 230 
treatment, 230 
tubercular, 229 
diagnosis, 229 
etiology, 229 

tubercle bacillus, 229 
symptoms, 229 
treatment, 229 



Peritoneum, diseases of, 227-231 
Perityphlitis, 215, 216 
Pertussis (see also Wliooping-cough) 
37 

Pest, 124 
Pharyngitis, 178 

acute, 178 

chronic. 179 
Pharynx, diseases of. 178, 179 
Phlebitis, 333 
Piles, 224 
Plague, 124 

etiology, 124 

bacillus pestis, 124 

history, 124 

symptoms, 124 

ti'eatment, 125 
Plasmodium malarise, 134, 135, 136 
Plethora, 335 

Pleura, diseases of, 285-292 
carcinoma, 292 
echinococcus, 292 
Pleurisy, 285-289 
acute, 285 
chronic, 286 
definition, 285 
dry, 286 
etiology, 285 
physical signs, 286 
suppurative, 287 
etiology, 287 
treatment, 289 

resection of rib, 289 
symptoms, 285 
treatment, 287 
Pneumatosis, 206 
Pneurao-hydro-tliorax, 290 
Pneumonia, 273-279 
broncho-, 277 
catarrhal, 277 
etiology, 277 

bacteria, 277 
symptoms, 278 
treatment, 279 
croupous, 273 
etiology, 273 

micrococcus crouposse, 273 
symptoms, 274 
' blood, 275 
treatment. 276 
fibrinous, 273 
genuine, 273 
influenza, 279 
lobar, 273 
lobular, 277 
tubercular, 280 



INDEX. 



399 



Pneumonia, typhoid, 280 

Pneumonokouiosis, 284 
Pneumo-pyo-thoras, 290 
Pneumothorax, 290 

etiology, 290 
gas-forming micro-organisms, 290 

syniptoms, 290 

treatment, 291 
Podagra, 349 
Polyjdiagia, 203 
Polvsarcia, 355 
Polyuria, 356, 361 
Pox (see also Sf/pkilis), 81 
Prostatorrhoea, 386 
Pseudoleukemia, 342 
Purpura, 344 

arthritic, 344 

fulminans, 345 

hsemorrhagica, 345 

Henoch's, 345 

myelopathic. 344 

pemphigoid, 345 

rbeumatica, 345 

symptomatic, 344 

urticans, 345 

venous stasis, 344 
pYfemia. 17 
Pyelitis, 371 

primary, 371 

secondary, 371 

symptoms, 372 
pyuria, 372 

treatment, 372 
Pyelonephritis, 371 
Pyloric incontinence, 206 
Pylorospasmus, 206 
Pyonephrosis, 371 
Pyuria, 369 

etiology, 369 



Q. 

Quinsy, 69 
definition, 69 
symptomatology, 69 
treatment, 70 



K. 

Eabies, 121 

Rachitis (see also Rickets), 353 
Ray-fungus, 132 
Recurrent fever, 104 
Relapsing fever, 104 



I Relapsing fever, diagnosis, 106 
etiology, 104 
symptomatology, 104 
eruption, 105 
incubation, 104 
invasion, 104 
relapse, 105 
treatment, 106 
serum, 106 
symptomatic, 106 
Eenal cirrhosis, 381 
diagnosis, 382 
prognosis, 383 
Eetropharyngeal abscess, 179 
etiology, 179 
symptoms, 180 
treatment, 180 
Rheumatism, 29 
acute articular, 30 
diagnosis, 31 
etiology, 30 
symptomatology, 30 
treatment, 31 
blisters. 32 
cold bath, 32 
diet, 31 
salicylates, 32 
chronic articular, 32 
diagnosis, 32 
symptoms, 32 
treatment, 33 

climato-therapv, 33 
heat, 33 

potassium iodide, 33 
gonorrhoeal, 33 
cause, 33 
occurrence, 33 
treatment, 33 
muscular, 33 
causes, 33 
diagnosis, 34 
symptomatology, 33 
treatment, 34 
varieties, 34 

cephalodynia, 34 
lumbago, 34 
occipito-frontal, 34 
pleurodynia, 34 
torticollis, 34 
nodular (see also Arthritis defor- 
mans), 352 
Rhinitis, 250-252 
acute, 250 

symptoms, 250 
treatment, 252 
chronic, 252 



400 



INDEX. 



Ehinitis, chronic, symptoms, 253 
treatment, 253 
hypersesthetica, 130 
syphilitic, 253 
Eickets, 353 
symptoms, 353 
fontanelles, 353 
rosary, 353 
treatment, 354 
Eock fever, 126 
Eotheln (see also Rubella), 49 
Eubella, 49 
definition, 49 
diagnosis, 50 
etiology, 49 
morbillosa, 50 
scarlatinosa, 50 

desquamation, 50 
symptoms, 49 
en an them, 49 
eruption, 50 
incubation, 49 
treatment, 50 
Eubeola (see also Measles), 44 

s. 

Saint Anthony's fire, 22 
Salivary glands, diseases of, 180 
Sand, 373 

Scarlatina (see also Scarlet fever), 50 
Scarlet fever, 50 

complications, 53 

albuminuria, 53 

nephritis, 53 
diagnosis, 53 
etiology, 50 
forms, 53 

abortive, 53 

fulminant, 53 

localized, 53 

malignant, 53 
immunity, 51 
in pigs, 51 
prognosis, 54 
prophylaxis, 54 

isolation, 54 

sodium sulphocarbolate, 55 
symptomatology, 51 
convulsions, 51 
en an them, 52 
exanthem, 52 
desquamation, 53 
incubation, 51 
invasion, 51 
strawberry tongue, 53 



Scarlet fever, symptomatology, tem- 
perature, 52 
treatment, 55 
bath, 55 
diet, 55 
serum, 55 
turpentine, 55 
Schonlein's disease, 345 
Scorbutus, 346 
Scurvy, 346 
symptoms, 346 
treatment, 347 
Sepsis, 17 

cryptogenetic, 18 
Septictemia, 17 
diagnosis, 19 
diflerential diagnosis, 19 

cerebro-spiual meningitis, 20 
endocarditis, 20 
joints, 20 
malaria, 20 

miliary tuberculosis, 20 
typhoid fever, 19 
uraemia, 20 
examination of the blood, 18 
metastatic affection, 19 
micro-organisms, 17 
prognosis, 21 
symptomatology, 18 
treatment, 21 
antiseptics, 21 
serum -therapy, 21 
Septico-pysemia, 17 
Serums (foot-note), 76 
Siderosis, 284 
Simon's triangles, 57 
Simple continued fever, 130 
Smallpox, 56 

complications, 59 
ears, 59 
eyes, 59 
heart, 59 
diagnosis, 59 

umbilicated vesicles, 60 
etiology, 56 
forms, 60 
confluent, 60 
hemorrhagic, 60 
history, 56 
prognosis, 60 
prophylaxis, 60 

vaccination, 60 
symptoms, 56 
desiccation, 59 
eruption, 57 
measles, 57 



INDEX. 



401 



Smallpox, symptoms, eruption on mu- 
cous membranes, 53 
papules, 58 
pustules, 53 
vesicles, 53 
incubation, 56 
invasion, 56 
Simon's triangles, 57 
temperature, 53 
secondary fever, 58 
treatment, 61 
of pitting, 61 
serum-injection, 61 
vaccination, 61 
Soft chancre, 86 
Spermatorrlicea, 336 
Spirillum cholerse, 110 
Spirochete, 104, 106, 170 
Splenic fever. 115 
Spotted fever, 26 
Stenosis, 309-315 
aortic, 312 
mitral, 309 
pulmonary, 315 
tricuspid. 314 
Stomach, atony. 207 

diseases of, iS7-203 
Stomatitis aphthosa, 171 
acute, 169 
catarrhalis, 169 
erythematotis. 169 
symptoms, 170 
treatment, 170 
gangrsenosa, 172 
etiology, 172 
symptoms. 173 
treatment, 173 
herpetica. 172 
symptoms. 171 
treatment. 171 
mycotica, 173 
simple, 169 
ulcerosa. 170 
Streptococcus erysipelatis, 22 
treatment of sarcoma, 23 
Sugar in urine, 358 
tests, 353 

Bremer's, 353 
fermentation, 359 
phenyl-hydrazin, 359 
Eobert5\'360 
Trommer's, 353 
Suppurative hepatitis, 238 
Swamp fever, 131 
Sweating fever, 127 
Syphilis, 31 

26— P. M. 



; Syphilis, congenital, 83 
signs, 83 
diagnosis, 83 
eruption, 83 
falling of the hair, 83 
etiology, 81 
hereditary, 81 
of the larynx, 258 
prognosis, 84 
prophylaxis, 84 
symptomatology, 82 
chancre, 82 
incubation, 82 
primary sore, 82 
second stage, 82 
third stage, 82 
treatment, 84 
excision of chancre, 84 
second stage, 84 
mercury, 84 
fumigation, 85 
inhalation, 85 
injection, 85 
internally, 85 
inunction, 84 
third stage, 85 

potassium iodide, 85 

T. 

Tsenia armata, 150 
cucumerina, 152 
diminuta, 153 
echinococcus, 148 
lata, 153 

nana (von Beneden), 148 
(V. Siebold), 153 

saginata. 152 

solium, 150 
Taeniae, 145 
Tapeworms, 145 

beef, 152 

broad, 153 

dog, 148 

etiology, 145 

pork, 150 

prophylaxis, 146 

treatment, 147 
calomel, 147 
male fern, 148 

unarmed. 152 
Tetanus, 118 

bacillus of. 113 

diagnosis. 119 

strychnine-poisoning, 119 

idiopathic, 113 



402 



INDEX. 



Tetanus, prognosis, 119 
prophylaxis, 119 
symptomatology, 118 

spasms, 119 
treatment, 120 
antitoxin, 120 
toxin, 120 
Thrombosis, 231 
Thrush, 173 

Tongue, diseases of, 174-176 

geographical, 175 

mapped, 175 
Tonsillitis, 176-178 

acute catarrhal, 176 

chronic, 178 

croupous, 176 

epidemic (see also Quinsy), 69 
lacunar, 176 

parenchymatous (see also Quinsy), 69 
suppurative (see also Quinsy), 69, 178 
Tonsils, diseases of, 176-178 

hypertrophy of, 178 
Trachea, diphtheria of, 261 
diseases of, 261 
tumors, 261 
Trematodes, 154 
Trichina spiralis, 165 
Trichinosis, 165 
Tricocephaliasis, 160 
Trismus, 118 
Tuberculin, 74, 76 

modifications (foot-note), 76 
new, 76 
old, 74 
test, 74 
Tuberculosis, 70 
diagnosis, 73 
sputum, 73 
tubercle bacillus, 73 
etiology, 70 

bacillus tuberculosis, 70 
environment, 71 
secondary infection, 71 
wounds, 71 
history, 70 
of the larynx, 258 
physical signs, 73 
prognosis, 75 
prophylaxis, 75 

milk inspection, 76 
symptomatology, 72 
expectoration, 72 
haemoptysis, 72 
hectic, 72 
night-sweats, 72 
treatment, 76 



Tuberculosis, treatment, drugs, 77 
nebulization of essential oils, 78 
new tuberculin, 76 

method of administration, 76 
solutions, 76, 77 
open air, 77 
sanitaria, 77 
Tumors of the intestines (see also In- 
testinal neoplasms), 225 
of the liver, 246, 247 
of the peritoneum (see Peritoneal 
neoplasms). 
Typhlitis, 215 
causes, 216 
symptoms, 216 
treatment, 216 
Typhoid fever, 92 
blood-test, 97 

Diazo reaction, 98 
Widal test, 97 
complications, 97 
heart-failure, 97 
perforation, 97 
septicsemia, 97 
etiology, 93 
history, 92 
prognosis, 99 
prophvlaxis, 99 
food, 99 
excreta, 99 
symptomatology, 93 
eruption, 93 
incubation, 93 
onset, 93 
spleen, 93 
stools, 93 

temperature, 93, 94 
tongue, 93 
treatment, 99, 101 
bathing, 100 
diet, 99 
drugs, 100 

hygienic surroundings, 100 
injections, 100 

laparotomy for perforation, 101 
nursing, 99 
sponging, 101 
stupes, 101 
Typhus abdorainalis, 92 
exanthemicas, 101 
fever, 101 

diagnosis, 103 
etiology, 102 
history, 102 
prognosis, 104 
symptomatology, 102 



INDEX. 



403 



Typhus fever, symptomatology, erup- 
tion, 102 
incubation, 102 
incursion, 102 
temperature, 103 
treatment, 104 

u. 

Ulcer of the duodenum, 212 
symptoms, 213 
treatment, 213 
of the intestine, 212 
of the stomach, 193 
Uraemia, 368 
toxin, 368 
Urethritis specifica, 86 
Urine, albumin (see also Albuminuria), 
364 

blood (see also Hematuria), 370 

chyle (see also Chyluria), 370 

incontinence, 385 

pus (see also Pyuria), 369 

sugar (see also Sugar in urine), 358 

V. 

Vaccination, 60 

etiology, 62 

history, 62 

method, 62 
Vaccinia, 61 

Valve-lesions (see also Valvular Dis- 
ease), 317 
physical signs, 317 
insufficiency, 317 
aortic, 317 
mitral, 317 
pulmonary, 318 
tricuspid, 318 
stenosis, 318 
aortic, 318 
mitral, 317 
pulmonary, 318 
tricuspid, 318 
treatment, 319 
bath, 320 
bromides, 320 
climate, 320 
exercise, 320 
nitroglycerin, 320 
plasters, 320 
rest, 319 
stimulants, 319 
Valves of the heart (see Valvular dis- 
ease). 



Valvular disease, 308-320 
combined lesions, 316 
insufficiency, 308, 311, 313, 314 
aortic, 311 
mitral, 308 
pulmonary, 314 
tricuspid, 313 
stenosis, 309, 312, 314, 315 
aortic, 312 
mitral, 309 
pulmonary, 315 
tricuspid, 315 
Varicella, 63 

symptomatology, 63 
treatment, 63 
Varices, 334 

Variola (see also Smallpox), 56 
Varioloid, 61 



w. 

Waterpox (see also Varicella), 63 
Weil's disease, 125, 244 
Whooping-cough, 37 
complications, 39 
contagion, 38 
definition, 37 
diagnosis, 39 

lingual ulcer, 39 

with measles, 39 
etiology, 37 
history, 37 
immunity, 38 
prophylaxis, 39 
symptomatology, 38 

chart in, 38, 39 

whoop, 38 
treatment, 40 

benzine vapor, 41 

drugs, 40 

grasping hyoid bone, 40 
local application, 40, 41 
naphthalin vapor, 40 . 
sulphur fumes, 41 
tussol, 40 
Wool-sorters' disease, 115 
Worm, Guinea, 163 
Worms, filiform, 157 
pin-, 159 
round-, 157 
whip-, 160 

X. 

Xerostomia, 180 



404 



INDEX. 



Y. 

Yellow fever, 107 
diagnosis, 109 

blood -test, 108 

icterus, 108 
etiology, 107 

amaril poison, 107 

bacillus icteroides, 107 

bacillus X, 107 
prognosis, 108 
prophylaxis, 109 



Yellow fever, symptomatology, 107 
black vomit, 108 
incubation, 107 
jaundice, 108 
onset, 107 
stages, 108 
treatment, 109 
cathartic, 109 
drugs, 109 
enemata, 109 
serum, 109 



CATALOGUE OF PUBLICATIONS OF 

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INDEX. 

ANATOMY. Gray, p. 11 ; Treves, 30 ; Gerrish, 11; Brockway, 4. 
DICTIOWAJilES. Dunglison, p. 8 ; Duane, 8 ; National, 4. 
PHYSICS. Draper, p. 8 ; Eobertson, 24 ; Martin & Rockwell, 20. 
PHYSIOLOGY. Foster, p. 10; Chapman, 5; Schofield, 25; Collins 

& Rockwell, 6. [Luff, 19 ; Remsen, 24. 

CHEMISTRY. Simon, p. 26 ; Attfield, 3 ; Martin & Rockwell, 20; 
PHARMACY. Caspari, p. 5. [Bruce, 4 ; Schleif, 25. 

MATERIA MEDICA. Calbretb, p. 6 ; Maisch, 19 ; Farquharson, 9 ; 
DISPENSATORY. National, p. 21. 

THERAPEUTICS. Hare, p. 13 ; Fothergill, 10 ; Whitla, 31 ; Hayem 
& Hare, 14 ; Bruce, 4 ; Schleif, 25 ; Cushny, 6. 

PRACTICE. Flint, p. 9 ; Loomis & Thompson, 19 ; Malsbary, 20. 

DIAGNOSIS. Musser, p. 21 ; Hare, 12; Simon, 25; Herrick, 15; Hutchi- 
son & Rainey, 16 ; Collins, 6. 

CLIMATOLOGY. Solly, p. 26 ; Hayem & Hare, 14. 

NERVOUS DISEASES. Dercum, p. 7 ; Gray, 11 ; Potts, 23. 

MENTAL DISEASES. Clouston, p. 5 ; Savage, 24 ; Folsom, 10. 

BACTERIOLOGY. Abbott, p. 2 ; Vaughan & Novy, 30 ; Senn's 
(Surgical), 25. Park, 22 ; Coates, 6. [Vale, 21. 

HISTOLOGY. Klein, p. 17 ; Schafer's, 25 ; Dunham, 8 ; Nichols & 

PATHOLOGY. Green, p. 12; Gibbes, 10; Coats, 6; Nichols & Vale, 21. 

SURGERY. Park, p. 22; Dennis, 7; Roberts, 24; Ashhurst, 3; Treves, 29; 
Cheyne & Burghard, 5 ; Gallaudet, 10. 
■ SURGERY— OPERATIVE. Stimson, p. 27 ; Smith, 26 ; Treves, 29. 

SURGERY— ORTHOPEDIC. Young, p. 31 ; Gibney, 10. 

SURGERY— MINOR. Wharton, p. 30. [Ballenger & 

FRACTURES and DISLOCATIONS. Stimson, p. 27. [Wippern, 3. 

OPHTH A.LMOLOGY. Norris & Oliver, p. 21; Nettleship, 21; Juler,17; 

OTOLOGY. Politzer, p. 23; Burnett, 5; Field, 9; Bacon, 4. 

LARYNGOLOGY and RHINOLOGY. Coakley, p. 6 ; 

DENTISTRY. Essig (Prosthetic), p. 9 ; Kirk (Operative), 17 ; Ameri- 
can System, 2 ; Coleman, 6; Burchard 4. 

URINARY DISEASES. Roberts, p. 24 ; Black, 4 ; Morris, 20. 

VENEREAL DISEASES. Taylor, p. 28 ; Hayden, 14 ; Cornil, 6 ; 
Likes, 19. 

SEXUAL DISORDERS. Fuller, p. 10 ; Taylor, 29. 

DERMATOLOGY. Hyde, p. 16 ; Jackson, 16 ; Pye-Smith, 24 ; Mor- 
ris, 20 ; Jamieson, 16 ; Hardaway, 12 ; Grindon, 12. 

GYNECOLOGY. American System, p. 3 ; Thomas & Mund4, 29 
Emmet, 9 ; Davenport, 7 ; May, 20 ; Dudley, 8 ; Crockett, 6. 

OBSTETRICS. American System, p. 3 ; Davis, 7 ; Parvin, 22 ; Play- 
fair, 23 ; King, 17 ; Jewett, 17 ; Evans, 9. 

PEDIATRICS. Smith, p. 26 ; Thomson, 29 ; Williams, 31 ; Tuttle, 30. 

HYGIENE. Egbert, p. 9 ; Richardson, 24 ; Coates, 6. 

MEDICAL JURISPRUDENCE. Taylor, p. 28. 

QUIZ SERIES, POCKET TEXT-BOOKS and MANUALS. 
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COLLINS (H. D.) AND ROCKWELL (W. H.). A POCKET 
TEXT-BOOK OF PHYSIOLOGY. In one handsome 12mo. volume 
of about 300 pages, with many illustrations. Cloth, $1.50, net. In press. 
Lea's Series of Pocket Text-hooks, edited by Bern B. Gallaudet, 
M. D. See page 18. 

CONDIE (D. FRANCIS). A PRACTICAL TREATISE ON THE DIS- 
EASES OF CHILDREN. Sixth edition, revised and enlarged. In 
one large 8vo. volume of 719 pages. Cloth, $5.25 ; leather, $6.25. 

CORNEL (V.). SYPHILIS: ITS MORBID ANATOMY, DIAGNO- 
SIS AND TREATMENT. Translated, with Notes and Additions, by 
J. Henry C. Simes, M.D. and J. William White, M.D. In one 
Svo. volume of 461 pages, with 84 illustrations. Cloth, $3.75. 

CROCKETT (M. A.). A POCKET TEXT-BOOK OF DISEASES 
OF WOMEN. In one handsome 12mo. volume of about 350 pages, 
with many illustrations. Cloth, $1.50, net. Shortly. Lea'' s Series of Pocket 
Text-hooks, edited by Bern B. GALLAroET, M. D. See page 18. 

CROOK (JAMES K.) ON MINERAL WATERS OF THE 
UNITED STATES. Octavo, 575 pages. Justreacly. Cloth, $3,50, we^. 

CULBRETH (DAVID M. R.). MATERIA MEDICA AND PHAR- 
MACOLOGY. In one handsome octavo volume of 812 pages, with 
445 illustrations. Cloth, $4.75. 



A thorough, authoritative and 
systematic exposition of its most 
important domain. — The Canada 
Lancet. 

This work ought to be at once 



adopted as the text-book in all col- 
leges of pharmacy and medicine. 
It is one of the most valuable works 
that have been issued. — The Ohio 
Medical Journal. 



CUSHNY (ARTHUR R.). TEXT-BOOK OF PHARMACOLOGY. 
Handsome 8vo., 728 pages, with 47 illus. Just ready. Cloth, $3.75, net. 



Lea Beothees & Co., Philadelphia and New Yoek. 7 



D ALTON (JOHN C). A TREATISE ON HUMAN PHYSIOLOGY. 
Seventh edition. Octavo, 722 pages, with 252 engravings. Cloth, 
$5; leather, $6. 



DOCTRINES OF THE CIRCULATION OF THE BLOOD. In 

one handsome 12mo. volume of 293 pages. Cloth, $2. 

DAVENPORT (F. H.). DISEASES OF WOMEN. A Manual of 
Gynecology. For the use of Students and Practitioners. New 
(3d) edition. In one handsome 12mo. volume of 387 pages, with 150 
illustrations. Cloth, $1.75, net. Just ready. 

DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR 
STUDENTS AND PRACTITIONERS. In one very handsome 
octavo volume of 546 pages, with 217 engravings and 30 full-page 
plates in colors and monochrome. Cloth, $5 ; leather, $6. 



This work must become the prac- 
titioner's text-book as well as the 
student's. It is up to date in every 
respect. — Va. Med. Semi-3Ionthly. 

A work unequalled in excellence. 
— Hie Chicago Clinical Review. 

Decidedly one of the best text- 



books on the subject. It is exception- 
ally useful from every standpoint. — 
Nashville Jour, of Med. and Surgery. 

From a practical standpoint the 
work is all that could be desired. A 
thoroughly scientific and brilliant 
treatise on obstetrics. —Bled. News. 



DAVIS (F. H.). LECTURES ON CLINIC A.L MEDICINE, 
edition. In one 12mo. volume of 287 pages. Cloth, $1.75. 



Second 



DE LA BECHE'S GEOLOGICAL OBSERVER. In one large octavo 
volume of 700 pages, with 300 engravings. Cloth, $4. 

DENNIS (FREDERIC S.) AND BILLINGS (JOHN S.). A SYS- 
TEM OF SURGERY. In contributions by American Authors. 
Complete work in four very handsome octavo volumes, containing 
3652 pages, with 1585 engravings and 45 full-page plates in colors 
and monochrome. Per volume, cloth, $6.00; leather, $7.00; half 
Morocco, gilt back and top, $8.50. For sale hy subscription only. 
Full prospectus free on application to the publishers. 



It is worthy of the position which 
surgery has attained in the great 
Republic whence it comes. — The 
London Lancet. 

It may be fairly said to represent 
the most advanced condition of 



American surgery and is thoroughly 
practical. — Annals of Surgery. 

No work in English can be con- 
sidered as the rival of this. — The 
American Journal of the Medical 
Sciences. 



DERCUl^f (FRANCIS X., EDITOR). A TEXT-BOOK ON 
NERVOUS DISEASES. By American Authors. In one handsome 
octavo volume of 1054 pages, with 341 engravings and 7 colored 
plates. Cloth, $6.00 ; leather, $7.00. Net. 



Representing the actual status of 
our knowledge of its subjects, and 
the latest and most fully up-to-date 
of any of its class. — Jour, of Amer- 
ican Med. Association. 

The most thoroughly up-to-date 
treatise that we have on this subject, 
— American Journal of Insanity. 

DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. 

Their Classification, History, Symptoms, Pathology and Treatment. 
Very handsome octavo, 240 pages, 46 engravings, and 9 full-page 
plates in colors. Limited edition, de luxe binding, $4. Net. 



The work is repi'esentative of the 
best methods of teaching, as devel- 
oped in the leading medical colleges 
of this country. — Alienist and Neu- 
rologist. 

The best text-book in any lan- 
guage. — The Medical Fortnightly. 



8 Lea Beothers & Co., Philadelphia and New York. 



DRAPER (JOHN C). MEDICAL PHYSICS. A Text-book for Stu- 
dents and Practitioners of Medicine. In one handsome octavo volume 
of 734 pages, with 376 engravings. Cloth, $4. 

DRUITT (ROBERT). THE PEINCIPLES AND PRACTICE OF 
MODERN SURGERY. A new American, from the twelfth London 
edition, edited by Stanley Boyd, F. R. C. S. In one large octavo 
volume of 965 pages, with 373 engravings. Cloth, $4 ; leather, $5. 

DUANE (AJL.EXANDER). THE STUDENT'S DICTIONARY OF 
MEDICINE AND THE ALLIED SCIENCES. New edition. Com- 
prising the Pronunciation, Derivation and Full Explanation of Medi- 
cal Terms, with much Collateral Descriptive Matter, Numerous Tables, 
etc. Square octavo of 658 pages. Cloth, $3.00 ; half leather, $3.25 ; 
full sheep, $3.75. Thumb-letter Index, 50 cents extra. 



convenience and thoroughness, — 
Medical Record. 

The best student's dictionary. — 
Canada Lancet. 



Far superior to any dictionary for 
the medical student that we know of. 
— Western Med. and Surg. Reporter. 

The book is brought accurately to 
date. It is a model of conciseness, 
DUDLEY (E. C). THE PRINCIPLES AND PRACTICE OF 
GYNECOLOGY. Handsome octavo of 652 pages, with 422 illustra- 
tions in black and colors. Cloth, $5.00, net ; leather, $6.00, net. Just 
ready. 



tice of modern gynecology. — Inter- 
national Medical Magazine. 



The book can be safely recom- 
mended as a complete and reliable 
exposition of the principles and prac- 
DUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE 
DISEASES OF WOMEN. Delivered in St. Bartholomew's Hospital. 
In one octavo volume of 175 pages. Cloth, $1.50. 
DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- 
ENCE. Containing a full explanation of the various subjects and 
terms of Anatomy, Physiology, Medical Chemistry, Pharmacy, Phar- 
macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- 
gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- 
ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. 
By RoBLEY DUNGLISON, M. D., LL. D., late Professor of Institutes 
of Medicine in the Jefferson Medical College of Philadelphia. Edited 
by Richard J. Dunglison, A. M., M. D. Twenty-first edition, thor- 
oughly revised and greatly enlarged and improved, with the Pronuncia- 
tion, Accentuation and Derivation of the Terms. With Appendix. 
In one magnificent imperial octavo volume of 1225 pages. Cloth, $7 ; 
leather, $8. Thumb-letter Index for quick use, 75 cents extra. 
The most satisfactory and authori- 1 scarcely be measured. — 3Ied. Record. 
tative guide to the derivation, defini- { Pronunciation is indicated by the 



tion and pronunciation of medical 
terms. — The CharlotteMed. Journal. 



phonetic system. The definitions are 
unusually clear and concise. The 
book is wholly satisfactory. — Uni- 
versity Medical Magazine. 



Covering the entire field of medi- 
cine, surgery and the collateral 
sciences, its range of usefulness can 
DUNHAM (EDWARD K.). MORBID AND NORMAL HIS- 
TOLOGY. Octavo, 450 pages,with 363 illustrations. Cloth, $3.25, net. 
Just ready. 

The best one-volume text or refer- 1 of published in America. — Virginia 
ence book on histology that we know I Medical Semi-Montlily . 
EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND 
MATERIA MEDICA. In one 8vo. volume of 544 pages. Cloth, $3.50 ; 
leather, $4.50. 

EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for 
Students and Practitioners. In one handsome Svo. volume of 676 pages, 
with 148 engravings. Cloth, $3 ; leather, $4. 



Lea Bkothebs & Co., Philadelphia and New Yoek. 9 



EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- 
TATION. In one 12mo. volume of 359 pages, with 63 illustrations. 
Just ready. Cloth, Net, $2.25. 



It is written in plain language, 
and, while primarily designed for 
physicians, it can be studied with 
profit by any one of ordinary intel- 



ligence. The writer has adapted it 
to American conditions, and his 
suggestions are, above all, practical. 

— The Neiv York Medical Journal. 



ELLIS (GEORGE VEVER). DEMONSTRATIONS IN ANATOMY. 
Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, 
$4.25 ; leather, $5.25. 

EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- 
TICE OF GYNECOLOGY. Third edition. Octavo, 880 pages, with 
150 original engravings. Cloth, $5 ; leather, $6. 

ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- 
GERY. Eighth edition. In two large octavo volumes containing 
2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. 

ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American 
Text-Books of Dentistry, page 2. 

EVANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS. 
In one handsome 12mo. volume of about 300 pages, with many illustra- 
tions. Cloth, $1.50, net. Shortly. Lea's Series of Pocket Text-books, 
edited by Bern B. Gallaudet, M. D. See page 18. 

FARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. 
Fourth American from fourth English edition, revised by Feank 
Woodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. 

FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE 
EAR. Fourth edition. In one octavo volume of 391 pages, with 73 
engravings and 21 colored plates. Cloth, $3.75. 



It is just such a work as is needed 
by every general practitioner. — 
American Practitioner and News. 



To those who desire a concise 
work on diseases of the ear, clear 
and practical, this manual com- 
mends itself in the highest degree. 
FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND 
PRACTICE OF MEDICINE. Seventh edition, thoroughly revised 
by Frederick P. Henry, M.D. In one large 8vo. volume of 1143 
pages, with engravings. Cloth, $5.00 ; leather, $6.00. 

The work has well earned its lead- medicine in the medical schools. — 
ing place in medical literature. — Northwestern Lancet. 
Medical Record. The best of American text-books 



The leading text-book on general 



on Practice. — Amer. Medico-Surgical 
Bulletin. 



— A MANUAL OF AUSCULTATION AND PERCUSSION ; of 
the Physical Diagnosis of Diseases of the Lungs and Heart, and of 
Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. 
In one handsome 12mo. volume of 274 pages, with 12 engravings. 

— A PRACTICAL TREATISE ON THE DIAGNOSIS AND 
TREATMENT OF DISEASES OF THE HEART. Second edition 
enlarged. In one octavo volume of 550 pages. Cloth, $4. 

— A PRACTICAL TREATISE ON THE PHYSICAL EXPLO- 
RATION OF THE CHEST, AND THE DIAGNOSIS OF DIS- 
EASES AFFECTING THE RESPIRATORY ORGANS. Second 
and revised edition. In one octavo volume of 591 pages. Cloth, $4.50. 

— MEDICAL ESSAYS. In one 12mo. vol. of 210 pages. Cloth, $1.38. 

— ON PHTHISIS : ITS MORBID ANATOMY ETIOLOGY, ETC. 
A Series of Clinical Lectures. In one 8vo. volume of 442 pages. 
Cloth, $3.50. 



10 Lea Beothers & Co., Philadelphia and New York. 



FOLSOM (C. F.). AN ABSTRACT OF STATUTES OF U. S. 
ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. 
Cloth, $1.50. With Clouston on Me^titaL Diseases (new edition, see 
page 6) $5.00, net, for the two works. 

FORMULARY, POCKET, see page 32. 

FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New 
(6th) and revised American from the sixth English edition. In one 
large octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50 ; 
leather, $5.50. 



Unquestionably the best book that 
can be placed in the student's hands, 
and as a work of reference for the 
busy physician it can scarcely be 



This single volume contains all 
that will be necessary in a college 
course, and all that the physician 
will need as well. — Dominion Med. 



excelled. — The Phila. Polyclinic. \ llonthly. 

FOTHERGHiL (J. 1>IILNER). THE PRACTITIONER'S HAND- 
BOOK OF TREATMENT. Third edition. In one handsome octavo 
volume of 664 pages. Cloth, $3.75 ; leather, $4.75. 

To have a description of the clearly stated, cannot fail to prove 
normal physiological processes of an a great convenience to many thought- 
organ and of the methods of treat- ful but busy physicians. The prac- 
ment of its morbid conditions tical value of the volume is greatly 
brought together in a single chapter, increased by the introduction of many 
and the relations between the two prescriptions — New York 3Ied, Jour. 

FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- 
ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- 
bodying Watts' Physical and Inorganic Chemistry. In one royal 
12mo. volume of 1061 pages, with 168 engravings, and 1 colored 
plate. Cloth, $2.75 ; leather, $3.25. 

FRANKLAKD (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY. 

In one handsome octavo volume of 677 pages, with 51 engravings and 
2 i^lates. Cloth, $3.75 ; leather, $4.75. 

FULLER (EUGENE). DISORDERS OF THE SEXUAL OR- 
GANS IN THE MALE. In one very handsome octavo volume of 
238 pages, with 25 engravings and 8 full-page plates. Cloth, $2. 



It is an interesting work, and one 
which, in view of the large and 
profitable amount of work done in 
this field of late years, is timely and 
well needed. — Medical Fortnightly. 

The book is valuable and instruc- 



tive and brings views of sound 
pathology and rational treatment to 
many cases of sexual disturbance 
whose treatment has been too often 
fruitless for good. — Annals of 
Surgery. 



FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR 
PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and 
Treatment. From second English edition. In one 8vo. volume of 475 
pages. Cloth, $3.50. 

GALLAUDET (BERN B.). A POCKET TEXT-BOOK ON SUR- 
GERY. In one handsome 12mo. volume of about 400 pages, with many 
illustrations. Cloth, $1.50, Shortly. Lea's Series of Pocket Text- 
hooks, edited by Bern B. Gallattdht, M. D. See page 18. 

GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. A 
Multum in Parvo. In one square octavo volume of 845 pages, with 
159 engravings. Cloth, $3.75. 

GIBBES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID 
HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. 

GIBNEY (V. P.). ORTHOPEDIC SURGERY. For the use of Practi- 
tioners and Students. In one 8vo. vol. profusely illus. Preparing. 



Lea Brothers & Co., Philadelphia and New York. 11 



GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. 
By American Authors. Edited by Frederic H. Gerrish, M. D. In one 
imp. octavo volume of 915 pages, with 950 illustrations in black and 
colors. Justready. Clth, $6.50; flexible waterproof, $7; leath,, $7.50, we/. 

In this, the first representative treatise on Anatomy jDroduced in America, 
no effort or expense has been spared to unite an authoritative text with the 
most successful anatomical pictures which have yet appeared in the woi'ld. 

The editor has secured the co-operation of the professors of anatomy in 
leading medical colleges, and with them has prepared a text conspicuous 
for its simplicity, unity and judicious selection of such anatomical facts as 
bear on physiology, surgery and internal medicine in the most compre- 
hensive sense of those terms. The authors have endeavored to make a 
book which shall stand in the place of a living teacher to the student, and 
which shall be of actual service to the practitioner in his clinical work, 
emphasizing the most important subjects, clarifying obscurities, helping 
most in the parts most difficult to learn, and illustrating everything by all 
available methods. 

GOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. 
vol. of 589 pages. Cloth, $2. See Student's Series of llanucils, p. 27. 

GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. 

New and thoroughly revised American edition, much enlarged in text, 
and in engravings in black and colors. In one imperial octavo volume 
of 1239 pages, with 772 large and elaborate engravings on wood. Price 
of edition with illustrations in colors : cloth, $7 ; leather, $8. Price 
of edition with illustrations in black : cloth, $6 ; leather, $7. 

This is the best single volume 
upon Anatomy in the English 
language. — Umversity 3Iedical Mag- 
azine. 

Gray's Anatomy affords the student 
more satisfaction than any other 
treatise with which we are familiar. 
— Buffalo 3Ied. Journal. 

The most largely used anatomical 
text-book published in the English 
language, — Annals of Surgery. 

Particular stress is laid upon the 
practical side of anatomical teach- 



ing, and especially the Surgical 
Anatomy. — Chicago Med. Recorder. 

Holds first place in the esteem of 
both teachers and students. — The 
BrooTclyn Medical Journal. 

The foremost of all medical text- 
books. — Medical Fortnightly. 

Gray's Anatomy should be the 
first work which a medical student 
should purchase, nor should he be 
without a copy throughout his pro- 
fessional career. — Pittsburg 3Iedical 
Revieiv. 

GRAY (LANDON CARTER). A TREATISE ON NERVOUS AND 
MENTAL DISEASES. For Students and Practitioners of Medicine. 
New (2d) edition. In one handsome octavo volume of 728 pages, with 
172 engravings and 3 colored plates. Cloth, $4.75; leather, $5.75. 



An up-to-date text-book upon 
nervous and mental diseases com- 
bined. A well-written, terse, ex- 
plicit, and authoritative volume 
treating of both subjects is a step in 
the direction of popular demand. — 
The Chicago Clinical Revieio. 

"The word treatment," says the 
author, "has been construed in the 
broadest sense to include not only 
medicinal and non-medicinal agents, 
but also those hygienic and dietetic 



measures which are often the physi- 
cian's best reliance." — The Journal 
of the American 3Iedical Association. 

The descriptions of the various 
diseases are accurate and the symp- 
toms and differential diagnosis are 
set before the student in such a way 
as to be readily comprehended. The 
author's long experience renders his 
views on therapeutics of great value. 
— The Journal of Nervous and 3Ien- 
tal Disease. 



12 Lea Brothers & Co., Philadelphia and New York. 



GREEN (T. HENRY). AN INTEODUCTION TO PATHOLOGY 
AND MORBID ANATOMY. New (8th) American from the eighth 
London edition. In one handsome octavo volume of 582 pages, with 
216 engravings and a colored plate. Cloth, $2.50, yiet. Just ready. 



A work that is the text-book of 
probably four-fifths of all the stu- 
dents of pathology in the United 
States and Great Britain stands in 
no need of commendation. The work 
precisely meets the needs and wishes 
of the general practitioner. — The 
American Practitioner and News. 

Green's Pathology is the text-book 



of the day — as much so almost as 
Gray's Anatomy. It is fully up-to- 
date in the record of fact, and so pro- 
fusely illustrated as to give to each 
detail of text sufficient explanation. 
The work is an essential to the prac- 
titioner — whether as surgeon orphys- 
ician. It is the best of up-to-date 
text-books. — VirginiaMed. Monthly. 



GREENE ("WILLiIAM H.). A MANUAL OF MEDICAL CHEM- 
ISTRY. For the Use of Students. Based upon Bowman's 3fedical 
Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. 



GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS- 
EASES, INJURIES AND MALFORMATIONS OF THE URINARY 
BLADDER, THE PROSTATE GLAND AND THE URETHRA. 
Third edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50. 

GRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN 
DISEASES. In one handsome 12mo. volume of 350 pages, Avith 
many illustrations. Shortly. Cloth, $1.50, net. Lea's Series of Pocket 
Text-hooks, edited by Been B. Gallaudet, M. D. See page 18. 

HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN 
Second American from the third English edition. In one octavo vol- 
ume of 554 pages, with 11 engravings. Cloth, $3.50. 

HAIili (WINFIEIiD S.) TEXT-BOOK OF PHYSIOLOGY. Octavo 
about 500 pages, richly illustrated. In press. 

HAMILTON (ALLAN MCLANE). NERVOUS DISEASES, THEIR 
DESCRIPTION AND TREATMENT. Second and revised edition. 
In one octavo volume of 598 pages, with 72 engravings. Cloth, $4. 



HARD A WAY (W. A.). MANUAL OF SKIN DISEASES. New (2d) 
edition. In one 12mo. volume of 560 pages, with 40 illustrations and 
2 plates. Cloth, $2.25, net. Just ready. 
The best of all the small books to day clinical experience. His great 
recommend to students and practi- strength is in diagnosis, descriptions 
tioners. Probably no one of our of lesions and especially in treat- 
dermatologists has had a wider every- ment. — Indiana 3Iedical Journal. 



HARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE 
USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. New 
(4th) edition. In one octavo volume of 623 pages, with 205 engravings 
and 14 full-page colored plates. Cloth, $5.00, net. Just ready. 



It is unique in many respects, and 
the author has introduced radical 
changes which will be welcomed by 
alJ. Anyone who reads this book 
will become a more acute observer, 
will pay more attention to the simple 
yet mdicative signs of disease, and 



he will become a better diagnosti- 
cian. This is a companion to Prac- 
tical Therapeutics, by the same 
author, and it is difficult to conceive 
of any two works of greater practical 
utility. — Medical Review. 



Lea Beothebs & Co., Philadelphia and New Yoek. 13 



HARE (HOBART AMORY). A TEXT-BOOK OF PKACTICAL 
THERAPEUTICS, with Special Reference to the Application of Reme- 
dial Measures to Disease and their Employment upon a Rational 
Basis. With articles on various subjects by well-known specialists. 
New C7th) and revised edition. In one octavo volume of 776 pages. 
Cloth, $3.75, net; leather, $4.50, 7iet. 



Its classifications are inimitable, 
and the readiness with which any- 
thing can be found is the most won- 
derful achievement of the art of in- 
dexing. This edition takes in all 
the latest discovered remedies. — 
The St. Louis Clinique. 

The great value of the work lies 
in the fact that precise indications 
for administration are given. A 
complete index of diseases and 
remedies makes it an easy reference 
work. It has been arranged so that 



it can be readily used in connection 
with Hare's Practical Diagnosis. 
For the needs of the student and 
general practitioner it has no equal. 
— Medical Sentinel. 

The best planned therapeutic work 
of the century. — American Prac- 
titioner and News. 

It is a book precisely adapted to 
the needs of the busy practitioner, 
who can rely upon finding exactly 
what he needs. — The National Med- 
ical Review. 



HARE (HOBART AMORY) ON THE MEDICAL COMPLICA 
TIONS AND SEQUELiE OF TYPHOID FEVER. Octavo, 276 
pages, 21 engravings and two full-page plates. Just ready. Cloth, 
$2.40, net. 

A very valuable production. One read with great -pro-^t.— Cleveland 
of the very best products of Dr. Journal of Medicine. 
Hare and one that every man can 

HARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC- 
TICAL THERAPEUTICS. In a series of contributions by eminent 
practitioners. In four large octavo volumes comprising about 4500 
pages, with about 550 engravings. Vol. IV., just ready. For sale by sub- 
scription only. Full prospectus free on application to the Publishers. 
Regular price. Vol. IV., cloth, $6 ; leather, $7 ; half Russia, $8. 
Price Vol. IV. to former or new subscribers to complete work, cloth, 
$5 ; leather, $6 ; half Russia, $7. Complete work, cloth, $20 ; leather, 
$24 ; half Russia, $28. 

The great value of Hare's System of Practical Therapeutics has led to a 
widespread demand for a new volume to represent advances in treatment 
made since the publication of the first three. More than fulfilling this 
request the Editor has secured contributions from practically a new corps 
of equally eminent authors, so that entirely fresh and original matter is 
ensured. The plan of the work, which proved so successful, has been fol- 
lowed in this new volume, which will be found to present the latest devel- 
opments and applications of this most practical branch of the medical art. 
The entire System is an unrivalled encyclopgedia on the practical parts of 
medicine, and merits the great success it has won for that reason. 



14 Lea Beothees & Co., Philadelphia and New Yoek. 



HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES 
AND PRACTICE OF MEDICINE. Fifth edition. In one 12ino. 
volume, 669 pages, witli 144 engravings. Cloth, $2.75 . 

A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 

12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. 

A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising 

Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- 
tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 
12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5. 



HAYDEN (JAMES R.). A MANUAL OF VENEREAL DISEASES. 
New (2d) edition. In one 12mo. volume of 304 pages, with 54 en- 
gravings. Cloth, $1.50, net. Just ready. 



It is practical, concise, definite 
and of sufiicient fulness to be satis- 
factory.— CAzcagro Clinical Review. 

This work gives all of the prac- 
tically essential information about 
the three venereal diseases, gon- 
orrhoea, the chancroid and syphilis. 
In diagnosis and treatment it is par- 



ticularly thorough, and may be 
relied upon as a guide in the man- 
agement of this class of diseases. — 
Northwestern Lancet. 

It is well written, up to date, and 
will be found very useful. — Inter- 
national Medical 3Iagazine. 



HAYEM (GEORGES) AND HARE (H. A.). PHYSICAL AND 
NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- 
tricity, Modifications of Atmospheric Pressure, Climates and Mineral 
Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume 
of 414 pageSjWith 113 engravings. Cloth, $3. 



This well-timed up-to-date volume 
is particularly adapted to the re- 
quirements of the general practi- 
tioner. The section on mineral 
waters is most scientific and prac- 
tical. Some 200 pages are given up 
to electricity and evidently embody 
the latest scientific information on 
the subject. Altogether this work 
is the clearest and most practical aid 
to the study of nature's therapeutics 
that has yet come under our obser- 
vation. — The Medical Fortnightly. 

For many diseases the most potent 
remedies lie outside of the materia 
medica, a fact yearly receiving wider 



recognition. Within this large 
range of applicability, physical 
agencies when compared with drugs 
are more direct and simple in their 
results. Medical literature has long 
been rich in treatises upon medical 
agents, but an authoritative work 
upon the other great branch of 
therajieutics has until, now been a 
desideratum. The section on climate, 
rewritten by Prof. Hare, will, for 
the first time, place the abundant 
resources of our country at the in- 
telligent command of American 
practitioners. — The Kansas City 
Medical Index. 



HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In 
one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See 
Student's Series of Manuals, page 27. 



HERMANN (L..). EXPERIMENTAL PHARMACOLOGY. A Hand- 
book of the Methods for Determining the Physiological Actions of 
Drugs. Translated by Robeet Meade Smith, M. D. In one 12iao. 
volume of 199 pages, with 32 engrayings. Cloth, $1.50= 



Lea Beothees & Co., Philadelphia and New Yoek. 15 



HERRICK (JAlVrES B.). A HANDBOOK OF DIAGNOSIS. lu 

one handsome 12mo. volume of 429 pages, -svith 80 engravings and 2 
colored plates. Cloth, $2.50. 

Excellently arranged, practical, | microscopical examination to be em- 
concise, up-to-date, and eminently i ployed in each class. The technique 
well fitted I'or the use of the prac- i of blood examination,including color 
titioner as well as of the student. — analysis, is very clearly stated. 
Chicago Jled. Recorder. | Uranalysis receives adequate space 

This volume accomplishes its ob- ; and care. — Xeiv York Med. Journal. 
jects more thoroughly and com-' We commend the book not only to 
pletely than any similar work yet • the undergraduate, but also to the 
published. Each section devoted" to physician who desires a ready means 
diseases of special systems is pre- of refreshing his kno wledge of diag- 
ceded with an exposition of the nosis in the exigencies of professional 
methods of physical, chemical and life. — 3Iemphis JlediMl Jlonihiy. 



HILlL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. 

HTLLIER (TH03IAS). A HANDBOOK OF SKIN DISEASES. 
Second edition. . In one roval 12mo. volume of 353 pages, with two 
plates. Cloth, $2.25. 

HIRST (BARTON C.) AND PIERSOL (GEORGE A. . HUMAN 
MONSTROSITIES. Magnificent folio, containing 220 pages of text 
and illustrated with 123 engravings and 39 large photographic plates 
from nature. In four parts, price each, S5. Limited edition. For sale 
by subscription only. 



HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS 
USED IN MEDICINE AND THE COLLATERAL SCIENCES. 
In one 12mo. voltime of 520 double-columned pages. Cloth, $1.50 ; 
leather, $2. 

HODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN, 
INCLUDING DISPLACEMENTS OF THE UTERUS. Second and 
revised edition. In one Svo. vol. of 519 pp., with illus. Cloth, $4.50. 

HOFF^IAJVN (FREDERICK) AND POWER (FREDERICK B.). 

A MANUAL OF CHEMICAL ANALYSIS, as Applied to the 
Examination of Medicinal Chemicals and their Preparations. Third 
edition, entirely rewritten and much enlarged. In one handsome octavo 
volume of 621 pages, with 179 engravings. Cloth, $4.25. 

HOmiES (TI3IOTHY). A TREATISE ON SURGERY. Its Prin- 
ciples and Practice. A new American from the fifth English edition. 
Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol- 
ume of lOOS^pages, with 428 engravings. Cloth, $6 ; leather, $7. 



— A SYSTEM OF SURGERY. With notes and additions by various 
American authors. Edited by John H. Packard, M. D. 'in three 
verv handsome Svo. volumes containing 3137 double-columned pages, 
with 979 engravings and 13 lithographic plates. Per volume, cloth, $6 ; 
leather, $7 ; half Russia, $7,50, For mU by subscription oniy. 



16 Lea Bbothebs & Co., Philadelphia and New York. 



HORNER (WILLiIAM E.). SPECIAL ANATOMY AND HIS- 
TOLOGY. Eighth edition, revised and modified. In two large 8vo. 
volumes of 1007 pages, containing 320 engravings. Cloth, $6. 



HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one 
octavo volume of 308 pages. Cloth, $2.50. 



HUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL 
METHODS. A GUIDE TO THE PRACTICAL STUDY OF 
MEDICINE. In one 12mo. volume of 562 pages, with 137 engrav- 
ings and 8 colored plates. Cloth, $3.00. 



A comprehensive, clear and re- 
markably up-to-date guide to clinical 
diagnosis. The illustrations are 
plentiful and excellent. As exam- 
ples of the more recent additions to 



medical knowledge which receive 
recognition, we mention Widal's 
test for typhoid and the Neuron 
theory of the nervous system. — 
llontreal Medical Journal. 



HUTCHINSON (JONATHAN). SYPHILIS. In one pocket-size 12mo. 
volume of 542 pages, with 8 chromo-lithographic plates. Cloth, $2.25. 
See Series of Clinical Manuals, p. 25. 



HYDE (JAMES NEVINS). A PRACTICAL TREATISE ON DIS- 
EASES OF THE SKIN. New (4th) edition, thoroughly revised. 
In one octavo volume of 815 pages, with 110 engravings and 12 full- 
page plates, 4 of which are colored. Cloth, $5.25 ; leather, $6.25. 



This edition has been carefully re- 
vised, and every real advance has 
been recognized. The work answers 
the needs of the general practitioner, 
the specialist, and the student. — The 
Ohio Med. Jour. 

A treatise of exceptional merit 
characterized by consci'=>ntious care 
and scientific accuracy. — Buffalo 
Med. Journal. 

A complete exposition of our 
knowledge of cutaneous medicine as 
it exists to-day. The teaching in- 
culcated throughout is sound as well 



as practical. — The American Jour- 
nal of the 3Iedical Sciences. 

It is the best one-volume work 
that we know. The student who 
gets this book will find it a useful 
investment, as it will well serve him 
when he goes into practice. — Vir- 
ginia Medical Semi-Monthly. 

A full and thoroughly modern 
text-book on dermatology. — The 
Pittsburg 3Iedical Review. 

It is the most practical hand- 
book on dermatology with which we 
are acquainted. — The Chicago Med- 
ical Recorder. 



JACKSON (GEORGE THOMAS). THE READY-REFERENCE 
HANDBOOK OF DISEASES OF THE SKIN. New (3d) edition. 
In one 12mo. volume of 637 pages, with 75 illustrations and a colored 
plate. Just ready. Cloth, $2.50, net. 

As a student's manual, it may be ( Without doubt forms one of the 
considered beyond criticism. The best guides for the beginner in der- 
book is singularly full.— ^SY. Louis matology that is to be found in the 
Medical and Surgical Journal. \ English language. — Medicine. 



JAMIESON (W. AJLLiAN). DISEASES OF THE SKIN. Third 
edition. In one octavo volume of 656 pages, with 1 engraving and 9 
double-page chromo-lithographic plates. Cloth, $6. 



Lea Beothess & Co., Philadelphia and New York. 17 



JEWETT (CHARLES). ESSENTIALS OF OBSTETEICS. In one 
12mo. volume of 356 pages, with 80 engravings and 3 colored plates. 
Cloth, $2.25. Just ready. 



An exceedingly useful manual for 
student and practitioner. The au- 
thor has succeeded unusually well 
in condensing the text and in arrang- 



ing it in attractive and easily tangi- 
ble form. The book is well illus- 
trated throughout. — Nashville Jour, 
of Medicine and Surgery. 



— THE PEACTICE OF OBSTETEICS. By American Authors. 
One large octavo volume of 763 pages, with 441 engravings in black 
and colors, and 22 full-page colored plates. Just ready. Cloth, 
$5.00, net; leather, $6.00, net. 

the book abounds. The work is 
sure to be popular with medical 
students, as well as being of extreme 
value to the practitioner. — The 
Medical Age. 



A clear and practical treatise upon 
obstetrics by well-known teachers of 
the subject. A special feature of 
this work would seem to be the 
excellent illustrations with which 



JONES (C. HANDFIELD). CLINICAL OBSEEVATIONS ON 
FUNCTIONAL NEEVOUS DISOEDEES. Second American edi- 
tion. In one octavo volume of 340 pages. Cloth, $3.25. 



JULiER fHENRY). A HANDBOOK OF OPHTHALMIC SCIENCE 
AND PEACTICE. Second edition. In one octavo volume of 549 
pages, witli 201 engravings, 17 chromo-lithographic plates, test-types of 
Jaeger ami Snellen, and Holmgren's Color-Blindness Test. Cloth, 
$5.50 ; leather, $6.50. 

The volume is particularly rich in \ color blindness, etc. The sections 
matter of practical value, such as j devoted to treatment are singularly 
directions for diagnosing, use of full and concise. — 3Iedical Age. 
instruments, testing for glasses, for | 



KING (A. F. A.). A MANUAL OF OBSTETEICS. Seventh edition. 
In one 12mo. volume of 573 pages, with 223 illustrations. Cloth, 
$2.50. 

From first to finish it is thoroughly cyclopedias. The well-arranged 
practical, concise in expression, well index renders the book useful to 
illustrated, and includes a statement the practitioner who is in haste to 
of nearly every fact of importance refresh his memory. — Virginia 
discussed in obstetric treatises or \ 3Iedical Semi-Monthly. 



KIRK (EDWARD C). OPEEATIVE DENTISTEY. Handsome 
octavo of 700 pages, with 751 illustrations. Just ready, ^qq American 
Text-Books of Dentistry , page 2. 



We have only the highest praise 
for this valuable work. It is replete 
in every particular, and surpasses 
anything of the kind heretofore at- 



tempted. We can heartily recom- 
mend it to the profession. — The 

Ohio Dental Journal. 



KLiEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In 
one 12mo. volume of 506 pages, with 296 engravings. Just ready. 
Cloth, $2.00, net. See Student's Series of Manuals, page 27. 

It is the most complete and con- | This work deservedly occupies a 
cise work of the kind that has yet ] first place as a text-book on his- 
emanated from the press. — The Med- tology. — Canadian Pract it ioner . 
ical Age. 1 



18 Lea Beothees & Co., Philadelphia and New Yoek. 



LiANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one 
handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. 

LfA ROCHE (R.). YELLOW FEVER. In two 8vo. volumes of 1468 
pages. Cloth, $7. 



liAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY- 
BOOK OF OPHTHALMIC SURGERY. Second edition. In one 
octavo volume of 227 pages, with 66 engravings. Cloth, $2,75. 

LEA'S SERIES OF POCKET TEXT-BOOKS, edited by Bern 
B. Gallaudet, M. D. Covering the entire field of Medicine in a 
series of 16 very handsome cloth-bound 12mo. volumes of 350-450 
pages each, profusely illustrated. Compendious, clear, trustworthy and 
modern, and issued at the very moderate price of $1.50, net, per 
volume. The following volumes constitute the series. 

COATES' Bacteriology and Hygiene. Brockway's Anatomy. Collins 
and Rockwell's Physiology. Martin and Rockwell's Chemistry 
and Physics. NiCHOLS and Vale's Histology and Pathology. 
Schleif's Materia Medica, Therapeutics, Medical Latin, etc. Mals- 
baPvY's Practice of Medicine. Collins' Diagnosis. Potts' Nervous 
and Mental Diseases. Gallaitdet's Surgery. Likes' Genito- 
urinary and Venereal Diseases. Grindon's Dermatology. Ballen- 
GER and Wippern's Diseases of the Eye, Ear, Throat and Nose. 
Evans' Obstetrics. Crockett's Gynecology. Tuttle's Diseases of 
Children. 

For separate notices see under various authors' names. 

LiEA (HENRY C). A HISTORY OF AURICULAR CONFESSION 
AND INDULGENCES IN THE LATIN CHURCH. In three 
octavo volumes of about 500 pages each. Per volume, cloth, $3.00. 

— CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN; 

CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMIN ATI - 
THE ENDEMONIADAS ; EL SANTO NljfO DE LA GUARDIA; 
BRIANDA DE BARDAXI. 12mo., 522 pages. Cloth, $2,50. 

FORMULARY OF THE PAPAL PENITENTIARY. In one 

octavo volume of 221 pages, with frontispiece. Cloth, $2.50. 



— SUPERSTITION AND FORCE ; ESSAYS ON THE WAGER 
OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND 
TORTURE. Fourth edition, thoroughly revised. In one hand- 
some royal 12mo. volume of 629 pages. Cloth, $2.75. 



STUDIES IN CHURCH HISTORY. The Rise of the Temporal 

Power — Benefit of Clergy — Excommunication. New edition. In one 
handsome 12mo. volume of 605 pages. Cloth, $2.50. 

AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY 

IN THE CHRISTIAN CHURCH. Second edition. In one hand- 
some octavo volume of 685 pages. Cloth, $4.50. 

UEHMANN (C. G.). A MANUAL OF CHEMICAL PHYSIOLOGY. 
In one 8vo. volume of 327 pages, with 41 engravings. Cloth, $2.25. 



Lea Brothers & Co., Philadelphia and New "York. 19 



LIKES (SYLVAN H.). A POCKET TEXT-BOOK OF GENITO- 
UEINARY AND VENEREAL DISEASES. In one handsome 
12rao. volume of about 350 pages, with many illustrations. Shortly. 
Cloth, $1.50, net. Lea's Series of Pocket Text-books, edited by Bern 
B. GALLArcET, M. D. See page 18. 

LOOMIS (ALFRED L.) AND THOMPSON (W. OILMAN, 
EDITORS). A SYSTEM OF PRACTICAL MEDICINE. In 
Contributions by Various American Authors. In four very hand- 
some octavo volumes of about 900 pages each, fully illustrated in 
in black and colors. Comjylete work noio ready. Per volume, cloth, 
$5; leather, $6 ; half Morocco, $7. For sale hy subscription only. 
Full prospectus free on application to the Publishers. See American 
System of Practical lledicine, page 2. 

LUFF (ARTHUR P.). MANUAL OF CHEMISTRY, for the use of 
Students of Medicine. In one 12mo. volume of 522 pages, with 36 
engravings. Cloth, $2. See Student's Series of llanuals, page 27. 

LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one 

very handsome octavo volume of 925 pages, with 170 engravings. 
Cloth, $4.75 ; leather, $5.75. 

Complete, concise, fully abreast of Practical, systematic, complete and 

the times and needed by all students well balanced. — Chicago 3Ied. Re- 

and practitioners. — Univ. 3fed. 3Iag. corder. 

An exceedingly valuable text-book. 



LYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo 
volume of 362 pages. Cloth, $2.25. 

MACKENZIE (JOHN NOLAND). ON THE NOSE AND THROAT. 
Handsome octavo, about 600 pages, richly illustrated. Preparing. 

MAISCH (JOHN M.). A MANUAL OF ORGANIC MATERIA 
MEDICA. New (7th) edition, thoroughly revised by H. C. C. Maisch, 
Ph. G., Ph. D. In one very handsome 12mo. volume of 512 pages, with 
285 engravings. Just ready. Cloth, $2.50, net. 



Used as text-book in every college 
of pharmacy in the United States 
and recommended in medical col- 
leges. — American Therapist. 

Noted on both sides of the Atlantic 
and esteemed as much in Germany as 



in America. The work has no equal. 
— Dominion Med. Monthly. 

The best handbook upon phar- 
macognosy of any published in this 
country. — Boston Med. & Sar. Jonr. 



20 Lea Beothees & Co., Philadelphia and New Yobk. 



MALSBARY (GEORGE E.). A POCKET TEXT-BOOK OF 
THEOEY AND PRACTICE OF MEDICINE. In one handsome 
12mo. volume of about 350 pages. Cloth, |1.50, net. Shortly. Lea's 
Series of Pocl-et Text-hooks, edited by Been B. Gallaudet, M. D. 
See page 18. 

MANUAXiS. See StudenVs Quiz Series, page 27, Student's Series of 
Manuals, page 27, and Series of Clinical Manuals, page 25. 



MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. 

volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

MARTIN (EDWARD). A MANUAL OF SURGICAL DIAGNOSIS. 
In one 12mo. volume of about 400 pp., fully illustrated. Preparing. 



MARTIN (WALTON) AND ROCKWELL (WM. H ). A POCKET 
TEXT-BOOK OF CHEMISTRY AND PHYSICS. In one hand- 
some 12mo. volume of about 350 pages, with many illustrations. Cloth, 
$1.50, net. Shortly. Lea s Series of Pocket Text-books, edited by 
Been B. Gallaudet, M. D. See page 18. 



MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For 
the use of Students and Practitioners. Second edition, revised by L. 
S. Rau, M. D. In one 12mo. volume of 360 pages, with 31 engrav- 
ings. Cloth, $1.75. 

MEDICAL NEWS POCKET FORMULARY, see page 32. 



MITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS 
DISEASES. In one 12mo. volume of 299 pages, with 19 engravings 
and 2 colored plates. Cloth, $2.50. Of the hundred numbered copies 
with the Author's signed title page a few remain ; these are offered 
in green cloth, gilt top, at $3.50, net. 



The book treats of hysteria, recur- 
rent melancholia, disorders of sleep, 
choreic movements, false sensations 
of cold, ataxia, hemiplegic pain, 
treatment of sciatica, erythromelal- 
gia, reflex ocularneurosis, hysteric 



contractions, rotary movements in 
the feeble minded, etc. Few can 
speak with more authority than the 
author. — The Journal of the Ameri- 
can Medical Association. 



MITCHELL (JOHN K.). REMOTE CONSEQUENCES OF IN- 
JURIES OF NERVES AND THEIR TREATMENT. In one 
handsome 12mo. volume of 239 pages, with 12 illustrations. Cloth, $1.75. 



Injuries of the nerves are of fre- 
quent occurrence in private practice, 
and often the cause of intractable 
and painful conditions, conse- 
quently this volume is of especial 
interest. Doctor Mitchell has had 



access to hospital records for the last 
thirty years, as well as to the 
government documents, and has 
skilfully utilized his opportunities. 
—The Med. Age. 



MORRIS (MALCOLM). DISEASES OF THE SKIN. New (2d) 
edition. In one 12mo. volume of 601 pages, with 10 chromo-litho- 
graphic plates and 26 engravings. Cloth, $3.25, net. Just ready. 

MtriiLER (J.). PRINCIPLES OF PHYSICS AND METEOROL- 
OGY. In one large 8vo. vol. of 623 pages, with 538 cut^. Cloth, $4.50. 



Lea Beothees & Co., Philadelphia and New Yoek. 21 



MUSSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL 

DIAGNOSIS, for Students and Physicians. New (3d) edition, thor- 
oughly revised. In one octavo volume of about 1000 pages, with about 
220 engravings and 48 full-page colored plates. In i^ress. 
Notices of previous edition are appended. 



We have no work of equal value 
in English. — University 3Iedical 
Magazine. 

His descriptions of the diagnostic 
manifestations of diseases are accu- 
rate. This work will meet all the 
requirements of student and physi- 
cian. — The Medical News. 

From its pages may be made the 
diagnosis of every malady that 
afflicts the human body, including 
those which in general are dealt 
with only by the specialist. — North- 
western Lancet. 



It so thoroughly meets the precise 
demands incident to modern research 
that it has been adopted as a leading 
text-book by the medical colleges 
of this countiy. — North American 
Practitioner. 

Occupies the foremost place as a 
thorough, systematic treatise. — Ohio 
Ifedicai Journal. 

The best of its kind, invaluable to 
the student, general practitioner and 
teacher. — Montreal Medica I Journ al. 



NATIONAL DISPENSATORY. See StUle, 3Iaisch & Caspari, p. 27. 

NATIONAL FOR^rCJLARY. See Stille, Maisch & C asp arVs National 
Dispensatory, page 27. 

NATIONAL MEDICAL DICTIONARY. See Billings, page 4. 

NETTLESHIP (E.). DISEASES OF THE EYE. New (5th) American 
from sixth English edition, thoroughly revised. In one 12mo. volume 
of 521 pages, with 161 engravings, and 2 colored plates, test-types, 
formulae and color-blindness test. Cloth, $2.25. Just ready. 

By far the best student's text-book English language. — Journal of 
on the subject of ophthalmology and Medicine and Science. 
is conveniently and concisely ar- 1 The present edition is the result 
ranged. — The Clinical Review. ' of revision both in England and 

It has been conceded by ophthal- America, and therefore contains the 
mologists generally that this work latest and best ophthalmological 
for compactness, practicality and i ideas of both continents. — The Phy- 
clearness has no superior in thel sician and Surgeon. 

NICHOLS (JOHN B.) AND VALE (F. P.). A POCKET TEXT- 
BOOK OF HISTOLOGY AND PATHOLOGY. In one handsome 
12mo. volume of about 350 pages, with many illustrations. In press. 
Cloth, $1.50, net. lea's Series of Pocket Text-hooks, edited by Been 
B. GALLArDET, M. D. See page IS. 

NORRIS (WT^I. F.) AND OLI\^R (CHAS. A.). TEXT-BOOK OF 
OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 
engravings and 5 colored plates. Cloth, $5 ; leather, $6. 

A safe and admirable guide, well i best, the safest and the most com]:^ re- 
qualified to furnish a working hensive volume upon the subject that 
knowledge of ophthalmology. — has ever been offered to the Amer- 
Johns Hopkins Hospital Bulletin. ican medical public. — Annals of 

It is practical in its teachings. Ophthalmology and Otology. 
We unreservedly endorse it as the 



22 Lea Beothees & Co., Philadelphia and New Yoek. 



OWEN (EDMUND). SUEGICAL DISEASES OF CHILDEEN. 
In one 12mo. volume of 525 pages, with 85 engravings and 4 colored 
plates. Cloth, $2. See Series of Clinical Manuals, page 25. 

PARK (ROSWELL). A TREATISE ON SURGERY BY AMERI- 
CAN AUTHORS. New and condensed edition. In jiress. In one 
royal octavo volume of about 1250 pages, with about 1000 engravings 
and many full-page plates. ^I^-This work is also published in a 
larger edition, comprising two volumes. Volume I., General Surgery , 
799 pages, with 356 engravings and 21 full-page plates, in colors and 
monochrome. Volume II., Special Surgery, 800 pages, with 430 engra- 
vings and 17 full-page plates, in colors and monochrome. Per volume, 
cloth, $4.50 ; leather, $5.50. Net. 



The work is fresh, clear and practi- 
cal, covering the ground thoroughly 
yet briefly, and well arranged for 
rapid reference, so that it will be of 
special value to the student and busy 
practitioner. The pathology is 
broad, clear and scientific, while the 
suggestions upon treatment are 
clear-cut, thoroughly modern and 
admirably resourceful. — Johns Hop- 
kins Hospital BtUletin. 

The latest and best work written 
upon the science and art of surgery. 
Columbus lledical Journal. 

The illustrations are almost en- 
tirely new and executed in such a 



way that they add great force to the 
text. — The Chicago Medical Re- 
corder. 

The various writers have em- 
bodied the teachings accepted at 
the present hour. — The North Amer- 
ican Practitioner. 

Both for the student and practi- 
tioner it is most valuable. It is 
thoroughly practical and yet thor- 
oughly scientific. — Medical News. 

A truly modern surgery, not only 
in pathology, but also in sound 
surgical therapeutics. — New Or- 
leans Med. and Surgical Journal. 



PARK (WILLIAM H.). BACTERIOLOGY IN MEDICINE AND 
SURGERY. 12mo., about 550 pages, fully illustrated. In press. 

PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS 
CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- 
MENT. In one octavo volume of 272 pages. Cloth, $2.50. 

PARVIN (THEOPHILUS). THE SCIENCE AND ART OF OB- 
STETRICS. Third edition. In one handsome octavo volume of 
677 pages, with 267 engravings and 2 colored plates. Cloth, $4.25 ; 
leather, $5.25. 



In the foremost rank among the 
most practical and scientific medical 
works of the day. — diedical News. 

It ranks second to none in the 
English language. — Annals of Gyne- 
cology and Pediatry. 

The book is complete in every de- 
partment, and contains all the neces- 
sary detail required by the modern 



practising obstetrician. — Interna- 
tional 3Iedical Magazine. 

Parvin's work is practical, con- 
cise and comprehensive. We com- 
mend it as first of its class in the 
English language. — Medical Fort- 
nightly. 

It is an admirable text-book in 
every sense of the word. — Nashville 
Journal of Medicine and Surgery. 



Lea Beothees & Co., Philadelphia axd New Yoek. 23 



PEPPER'S SYSTEM OF MEDICINE. See page 3. 

PEPPER f A. J.). FOEEXSIC MEDICINE. In press. See Student's 
Series of Manuals, page 27. 

SUEGICAL PATHOLOGY. In one 12mo. volume of 511 pages, 

with 81 engravings. Cloth, $2. See Student's Series of Manuals, ip. 27. 

PICK iT. PICKERING \ FPvACTUEES AND DISLOCATIONS. 

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pijAyfair rw. s.). a teeatise on the science and 

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In the numerous editions which obstetrician. It holds a place among 
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QUIZ SERIES. See Student's Quiz Series, page 27. 

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REICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY. 

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A clear and lucid summary of an accurate observer and practical 



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Every practitioner of medicine 
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TAYLOR (ROBERT W.). THE PATHOLOGY AND TREAT- 
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Notices of previous edition are appended. 



odds 



the best work on 
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By loni 
venereal diseases. 
cal Monthly. 

In the observation and treatment 
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The clearest, most unbiased and 
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The best work on venereal dis- 
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kind. — The St. Louis 3Iedical and 
Surgical Journal. 



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TAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX- 
UAL DISORDERS IN THE MALE AND FEMALE. In one 
8vo. vol. of 448 pp., with 73 engravings and 8 colored plates. Cloth, 
$3. Net. 



It is a timely boon to the medical 
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patients intelligently. Sterility in 



the female is presented in an exhaus- 
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A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. 

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TAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for 
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802 pages. Cloth, $3.75. 

THOMAS (T. GAIL.LARD) AND MUNDE (PAUL F.). A PRAC 
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large and handsome octavo volume of 824 pages, with 347 engravings. 
Cloth, $5 ; leather, $6. 



The best practical treatise on the 
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It will be of especial value to the 
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most practical and at the same time 
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THOMPSON (SBR HENRY). CLINICAL LECTURES ON DIS- 
EASES OF THE URINARY ORGANS. Second and revised edi- 
tion. In one octavo vol. of 203 pp., with 25 engravings. Cloth, $2.25. 

THE PATHOLOGY AND TREATMENT OF STRICTURE 

OF THE URETHRA AND URINARY FISTULA. From the 
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THOMSON (JOHN). DISEASES OF CHILDREN. In one crown 

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TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER- 
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TREVES (FREDERICK). OPERATIVE SURGERY. In two 
8vo. vols, containing 1550 pp., with 422 illus. Cloth, $9 ; leath., $11. 

A SYSTEM OF SURGERY. In Contributions by Twenty-five 

English Surgeons. In two large octavo volumes. Vol. I., 1178 pages, 
with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 
487 engravings and 2 colored plates. Complete work, cloth, $16.00. 



30 Lea Brothees & Co., Philadelphia and New Yoek. 



TREVES (FREDERICK]. SURGICAL APPLIED ANATOMY. In 
one 12mo. volume of 540 pages, with 61 engravings. Cloth, $2. See 
StxidenVs Series of 3fanuals, page 27-. 

TUTTLiE (GEORGE M.). A POCKET TEXT-BOOK OF DISEASES 
OF CHILDREX. In one handsome 12mo. volume of about oOO pages, 
with many illustrations. Cloth, $1.50, net. Shortly. LecCs Series of 
Fochet Tcxt-hooJ:$, edited by Bern B. Gallatjdet, M. D. See p 18. 

VAUG^CAN (VICTOR C.) AND NOVY (FREDERICK G.). 

PTOMAINS, LEUCOMAINS, TOXINS AND ANTITOXINS, 
or the Chemical Factors in the Causation of Disease. New (3d) edition. 
In one 12mo. volume of 603 pages. Cloth, $3. 

The work has been brought down The present edition has been not 
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satisfactory. — Journal of the Ameri- \ hut also greatly enlarged, ample 
can Medical Association. consideration being given to the new 

The most exhaustive and most re- subjects of toxins and antitoxins. — 
cent presentation of the subject. — ' Tri-State Medical Journal. 
American Jonr. of the Med. Sciences. '' 



VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1899. 

Four styles : Weekly (dated for 30 patients); Monthly (undated for 
120 patients per month) ; Perpetual (undated for 30 patients each 
week); and Perpetual (undated for 60 patients each week). The 60- 
patient book consists of 256 pages of assorted blanks. The first three 
styles contain 32 pages of important data, thoroughly revised, and 
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With thumb-letter index for quick use, 25 cents extra. Special rates 
to advance-paying subscribers to The Medical News or The 
Amekican Journal of the Medical Sciences, or both. See p. 32. 

WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND 
PRACTICE OF PHYSIC. A new American from the fifth and 
enlarged English edition, with additions by H. Hartshorne, M. D. 
In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11. 

WEST (CHARIjES). lectures ON THE DISEASES PECULIAR 
TO WOMEN. Third American from the third English edition. In 
one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN 

CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1. 

WHARTON (HENRY R.). MINOR SURGERY AND BANDAG- 
ING. New (4th) edition. In one 12mo. vol. of about 600 pages, with 
about 500 engravings, many of which are photographic. Shortly. 
Notices of previous edition are appended. 



We know of no book which more 
thoroughly or more satisfactorily 
covers the ground of Minor Surgery 
and Bandaging. — Brooklyn 3Iedical 
Journal. 

Well written, conveniently ar- 
ranged and amply illustrated. It 
covers the field so fully as to render 
it a valuable text-book, as well as a 



work of ready reference for sur- 
geons. — North Amer. Practitioner. 

The part devoted to bandaging is 
perhaps the best exposition of the 
subject in the English language. It 
can be highly commended to the 
student, the practitioner and the 
specialist. — The Chicago Medical 
Recorder. 



Lea Beothees & Co., Philadelphia and New Yoek. 31 



WHITLA (WHiLIAM). DICTIONARY OF TREATMENT, OR 
THERAPEUTIC INDEX. Including Medical and Surgical Thera- 
peutics. In one square octavo volume of 917 pages. Cloth, $4. 



WILLIA3IS (DAWSON). THE MEDICAL DISEASES OF CHIL- 
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